The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAYSHORE MEDICAL CENTER 4000 SPENCER HWY PASADENA, TX 77504 March 18, 2011
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review and interview the facility failed to conduct an appropriate medical screening examination by ensuring a pregnant woman in labor with history of a previous cesarean delivery was seen and examined by a physician according to hospital protocol for high risk pregnancies. Citing one Patient named in a complaint.

Findings:

Patient #1

Complaint Narrative
Review of complaint narrative revealed documentation that Patient #1 arrived at Hospital SJ on 3/5/11 shortly after midnight via private automobile. Patient #1 told the ER Physician at Hospital SJ that the Nurse Midwife at Hospital EH sent her over so that she could have a vaginal delivery.

Further review of the narrative revealed information that Patient #1 was examined and was 5-6 cm dilated. A plan was developed to do a repeat cesarean delivery. Patient #1 was counseled on the risks of vaginal birth and informed her that because Hospital SJ did not have an operative report from her last delivery they were uncomfortable with allowing her a trial of labor. The patient understood and agreed to a repeat cesarean.

Hospital EH

Review of record titled patient activity record documented that the patient arrived on the Labor and Delivery unit on 3/5/11 at 22:20 hours.
Flow sheet documented the patient's vital signs were done at 22:30. Blood Pressure (B/P) 108/61, pulse 77, respirations 16 and temperature 97.7 degrees. She was having uterine contractions at a frequency of every 6-7 minutes lasting for 60-70 seconds. The quality of contraction was mild. She was dilated 4cm with 80% effacement. Membranes were intact.

Further review of the flow sheets dated 3/5/11 revealed documentation that at 23:00 Staff #51, Certified Nurse Midwife (CNM), was at the bedside to evaluate her. There was documentation at 23:04 that Patient #1 "states she wants to go back to Hospital SJ, she states she was there till 20:00 today and wants to have her baby there."

Review of Obstetrical History and Physical dated 3/5/11 revealed Patient #1 was examined at 23:05 by Staff #51. Patient gave history of having a cesarean section (C/S) 2/15/2006 for fetal distress. She had limited prenatal care with current pregnancy. She was recently seen at two hospitals and her plan for delivery a repeat C/S by 3/8/11 if she did not go into labor.

Impression after examination was IUP (Intra Uterine Pregnancy).
Plan was to discuss options for repeat C/S at Hospital EH - offer transfer to Hospital SJ if patient desires VBAC (vaginal birth after cesarean) "states my husband can drive me." "Hospital SJ called - spoke with Labor and Delivery about patient at 23:08." (no information of what was said)

Further review of flow sheet dated 3/5/11 at 23:11 revealed documentation that "patient dressed and discharge instruction given to go straight to Hospital SJ now, patient verbalized understanding. Patient escorted to family car in stable condition. Patient given choice to go via ambulance or personal car, patient and spouse state prefers own car."

Review of physician's order record, dated 3/5/11 at 23:30 revealed the following information:
Diagnosis: IUP (Intra Uterine Pregnancy) at 40 weeks and one day, previous C/S in labor. "Discharge from triage to go directly to Hospital SJ per patient request" signed by Staff #51.

Review of progress notes dated 3/5/11 23:30 documented the following information: "Spoke with Resident at Hospital SJ, Attending on call will not do vaginal birth after cesarean section (VBAC). Patient will need repeat C/S even if in labor and desires VBAC.

Staff #51 documented that she spoke to the Obstetrician on call at Hospital EH regarding the patient and the physician said he would offer a repeat C/S to the patient since VBAC is not available at Hospital EH. She went to discuss with patient, patient and spouse had already left Labor and Delivery unit.

Discharge instructions were given to the patient to go directly to Hospital SJ Labor and Delivery by the Triage Nurse. Called Hospital SJ Labor and Delivery to let them know that the patient was enroute."

Review of Discharge Summary dated 3/5/11 at 23:10 documented that Discharge provider was Staff #51. Patient's condition was stable, she was discharged to: Other
Teaching instruction given to patient and spouse, instructions understood. "Patient was to go directly to Hospital SJ is per patient request."

There was no documentation that a Physician saw and examined the patient prior to discharge or that a physician ordered a discharge for the patient.
The patient did not leave against medical advice she was discharged by facility staff and given discharge instructions.

Review of the facility's Hospital Clinical Guidelines for Midwifery service dated 12/1/2010 documented the following information:
"If a condition is identified in a patient receiving care from the CNM (Certified Nurse Midwife), which requires evaluation or management by a physician, the patient will be referred to the appropriate consultant."

Further review of the policy section titled "Known Conditions Requiring Referral To Physician Care":
"Obstetrical complications such as prior cesarean sections in labor (unless delivery is imminent)."

There was no evidence that Patient #1 was placed in the care of a physician. There was no physician's evaluation. The patient was discharged from the facility less than two hours after arrival on the Obstetric Unit.

Review of the facility's policy # LL.EM.005 dated 3/2008 described as EMTALA documented the following information:
Purpose: To establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment or an appropriate transfer for the individual as required by Emergency Medical Treatment and Active Labor Act (EMTALA).

Section IV documented that the evaluation of the patient is "an on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until the individual is stabilized or appropriately transferred. This evaluation must be documented in the individual's medical records prior to discharge or transfer. When stabilizing treatment is rendered for an EMC, medical records should indicate the treatment necessary, medications, treatment, surgeries and services provided, and their effect on the EMC, including screenings, tests, evaluations, impressions and diagnoses."

The facility did not follow their policy to provide an appropriate medical screening examination.

During an interview on 3/18/11 at the facility with Staff #51, she stated she did not discharge the patient, it was another nurse. According to Staff #51, she had a discussion with the hospital physician regarding the patient's desire for a vaginal birth, the Physician said he would offer a repeat C/S only. Spoke to staff at Hospital SJ and they also would only do a repeat C/S. Staff #51 said she went to speak to the patient and was informed by the triage nurse that the patient was discharged and instructed to go to Hospital SJ.

According to Staff #51 when she found out the patient was gone she was angry. She called Hospital SJ to alert them that the patient was enroute to their facility.

The Surveyor asked Staff #51 how the discharge situation was handled she stated she informed the Unit Director the following morning. Staff #51 did say the narrative notes she wrote, were written after the patient left.

During a telephone interview on 3/29/11 at 2:00 pm with Patient #1, she stated she was discharged and instructed to go directly to Hospital SJ. She went to Hospital SJ where they delivered her by cesarean section.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to provide stabilizing treatment for a patient in labor who went to the Labor and Delivery suite for her delivery. The patient was examined by Labor unit staff and diagnosed as being in labor. The facility staff discharged the patient from the facility without delivering the baby and placenta. Citing one Patient named in a complaint.

Findings:

Patient #1

Complaint Narrative
Review of complaint narrative revealed documentation that Patient #1 arrived at Hospital SJ on 3/5/11 shortly after midnight via private automobile. Patient #1 told the ER Physician at Hospital SJ that the Nurse Midwife at Hospital EH sent her over so that she could have a vaginal delivery.

Further review of the narrative revealed information that Patient #1 was examined and was 5-6 cm dilated. A plan was developed to do a repeat cesarean delivery. Patient #1 was counseled on the risks of vaginal birth and informed her that because Hospital SJ did not have an operative report from her last delivery they were uncomfortable with allowing her a trial of labor. The patient understood and agreed to a repeat cesarean.

Record at Hospital EH

Review of record titled patient activity record documented that the patient arrived on the Labor and Delivery unit on 3/5/11 at 22:20 hours.
Flow sheet documented the patient's vital signs were done at 22:30. Blood Pressure (B/P) 108/61, pulse 77, respirations 16 and temperature 97.7 degrees. She was having uterine contractions at a frequency of 6-7 minutes lasting for 60-70 seconds. The quality of contraction was mild. She was dilated 4cm with 80% effacement. Membranes were intact.

Further review of the flow sheets dated 3/5/11 revealed documentation that at 23:00 Staff #51, Certified Nurse Midwife (CNM), was at the bedside to evaluate her. There was documentation at 23:04 that Patient #1 "states she wants to go back to Hospital SJ, she states she was there till 20:00 today and wants to have her baby there."

Review of Obstetrical History and Physical dated 3/5/11 revealed Patient #1 was examined at 23:05 by Staff #51. Patient gave history of having a cesarean section (C/S) 2/15/2006 for fetal distress. She had limited prenatal care with current pregnancy. She was recently seen at two hospitals and her plan for delivery a repeat C/S by 3/8/11 if she did not go into labor.

Impression after examination was IUP (Intra Uterine Pregnancy).
Plan was to discuss options for repeat C/S at Hospital EH - offer transfer to Hospital SJ if patient desires VBAC (vaginal birth after cesarean) "states my husband can drive me." "St. Joseph's called - spoke with Labor and Delivery about patient at 23:08." (no information of what was said)

Further review of flow sheet dated 3/5/11 at 23:11 revealed documentation that "patient dressed and discharge instruction given to go straight to Hospital SJ now, patient verbalized understanding. Patient escorted to family car in stable condition. Patient given choice to go via ambulance or personal car, patient and spouse state prefers own car."

Review of physician's order record, dated 3/5/11 at 23:30 revealed the following information:
Diagnosis: IUP (Intra Uterine Pregnancy) at 40 weeks and one day, previous C/S in labor. "Discharge from triage to go directly to Hospital SJ per patient request" signed by Staff #51.

Review of progress notes dated 3/5/11 23:30 documented the following information: "Spoke with Resident at Hospital SJ, Attending on call will not do vaginal birth after cesarean section (VBAC). Patient will need repeat C/S even if in labor and desires VBAC."

Staff #51 documented that she spoke to the Obstetrician on call at Hospital EH regarding the patient and the physician said he would offer a repeat C/S to the patient since VBAC is not available at Hospital EH. She went to discuss with patient, patient and spouse had already left Labor and Delivery unit.

Discharge instructions were given to the patient to go directly to Hospital SJ Labor and Delivery by the Triage Nurse. Called Hospital SJ Labor and Delivery to let them know that the patient was enroute.

Review of Discharge Summary dated 3/5/11 at 23:10 documented that Discharge provider was Staff #51. Patient's condition was stable, she was discharged to: Other
Teaching instruction given to patient and spouse, instructions understood. "Patient was to go directly to Hospital SJ, is per patient request."

Review of the facility 's policy # LL.EM.005 dated 3/2008 described as EMTALA documented the following information:

"Purpose: To establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment or an appropriate transfer for the individual as required by Emergency Medical Treatment and Active Labor Act (EMTALA)."

Section IV documented that the evaluation of the patient is "an on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until the individual is stabilized or appropriately transferred. This evaluation must be documented in the individual's medical records prior to discharge or transfer. When stabilizing treatment is rendered for an EMC, medical records should indicate the treatment necessary, medications, treatment, surgeries and services provided, and their effect on the EMC, including screenings, tests, evaluations, impressions and diagnoses."

The facility failed to provide evidence that the patient had continued monitoring, no tests or continued assessment was documented
the facility discharged the patient approximately an hour after she arrived at the facility without delivering the patient and the placenta.

Patient #1 returned a phone call to the Surveyor on 3/29/11 at 2:00 pm.
During the interview the patient stated she went to Hospital EH because she had gone earlier to Hospital SJ was told she was half a centimeter dilated, her contractions were irregular she was not in labor and was sent home.

According to Patient #1 her pain was getting very bad so she went to Hospital EH. At Hospital EH the "Doctor" examined her and said she was 4cm dilated and was in labor. She told the "Doctor" that she was at Hospital SJ earlier and was sent home. The "Doctor told her she would call Hospital SJ, afterwards she was told four times that if she went back to Hospital SJ, they would do a vaginal delivery there because Hospital EH will only do a repeat C/S."

Patient #1 stated she was surprised at the information because Hospital SJ had told her they would only do a repeat C/S because they did not have any information regarding her previous delivery and the risk of a ruptured uterus.

Patient #1 stated she was discharged and instructed to go directly to Hospital SJ. She was given instructions and the Nurse walked her to the waiting room where her husband was waiting. She walked to her car which was parked outside.

When asked by the Surveyor if she was offered an ambulance, Patient #1 stated the Nurse told her she could go in an ambulance or her car and since her car was there she decided to go by car. No one told her it was a risk to go by private car.

Hospital SJ

Review of Obstetric Triage Record at Hospital SJ revealed Patient #1 was admitted on [DATE] at eight (8) minutes after midnight. Reason for admission was documented as labor with contractions at a pain scale of 7/10 (10 being the most severe pain). She was examined and there was documentation that the Impression was: Active labor, with plan for a repeat cesarean section.
Examination: Temperature 98.0 degrees, pulse 70, respiration 108. Gestation was 40 weeks and 2 days with an expected delivery date of 3/4/11.
Vaginal examination: She was 5-6 centimeters dilated 80% effaced at station (-2). Irregular contractions every three (3) minutes. The patient gave medical history of having Diabetes.

Review of Labor and Delivery record revealed a male infant weighing six (6) pounds, four (4) ounces was delivered by C/S at 3:20 am on 3/6/11. The patient had Meconium stained liquor. (Approximately three and a half hours after arriving at the hospital from Hospital EH.)

During a telephone interview on 3/17/11 at 8:15 am with the Quality Director at Hospital SJ, she stated the Nurse Midwife at Hospital EH called Hospital SJ on 3/5/11 at about 11:30 pm requesting to transfer Patient #1 for a vaginal delivery after C/S. The physician informed the Nurse Midwife that Hospital SJ would only do a repeat C/S for the patient and since Hospital EH offers the same service and the patient is already there and in labor they should keep and treat the patient.

During a telephone interview on 3/31/11 with Physician T from Hospital SJ he stated it was a complete surprise to him when the patient showed up in her own private vehicle, in labor, from Hospital EH. According to Physician T, Hospital EH did not call them to say the patient was on her way.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure an appropriate transfer was in place for a patient in active labor that was discharged from the Labor and Delivery suite with instructions to go in her private car directly to Hospital SJ (12.6 miles away). The patient had a history of previous cesarean section. Citing one Patient named in a complaint.

Findings:

Patient #1
Complaint Narrative
Review of complaint narrative revealed documentation that Patient #1 arrived at Hospital SJ on 3/5/11 shortly after midnight via private automobile. Patient #1 told the ER Physician at Hospital SJ that the Nurse Midwife at Hospital EH sent her over so that she could have a vaginal delivery.

Further review of the narrative revealed information that Patient #1 was examined and was 5-6 cm dilated. A plan was developed to do a repeat cesarean delivery. Patient #1 was counseled on the risks of vaginal birth and informed her that because Hospital SJ did not have an operative report from her last delivery they were uncomfortable with allowing her a trial of labor. The patient understood and agreed to a repeat cesarean.

Record at Hospital EH

Review of record titled patient activity record documented that the patient arrived on the Labor and Delivery unit on 3/5/11 at 22:20 hours.
Flow sheet documented the patient's vital signs were done at 22:30. Blood Pressure (B/P) 108/61, pulse 77, respirations 16 and temperature 97.7 degrees. She was having uterine contractions at a frequency of 6-7 minutes lasting for 60-70 seconds. The quality of contraction was mild. She was dilated 4cm with 80% effacement. Membranes were intact.

Further review of the flow sheets dated 3/5/11 revealed documentation that at 23:00 Staff #51, Certified Nurse Midwife (CNM), was at the bedside to evaluate her. There was documentation at 23:04 that Patient #1 "states she wants to go back to Hospital SJ, she states she was there till 20:00 today and wants to have her baby there."

Review of Obstetrical History and Physical dated 3/5/11 revealed Patient #1 was examined at 23:05 by Staff #51. Patient gave history of having a cesarean section (C/S) 2/15/2006 for fetal distress. She had limited prenatal care with current pregnancy. She was recently seen at two hospitals and her plan for delivery a repeat C/S section by 3/8/11 if she did not go into labor.

Impression after examination was IUP (Intra Uterine Pregnancy).
Plan was to discuss options for repeat C/S at Hospital EH - offer transfer to Hospital SJ if patient desires VBAC (vaginal birth after cesarean) "states my husband can drive me." "Hospital SJ called - spoke with Labor and Delivery about patient at 2308." (no information of what was said)

Further review of flow sheet dated 3/5/11 at 23:11 revealed documentation that "patient dressed and discharge instruction given to go straight to Hospital SJ now, patient verbalized understanding. Patient escorted to family car in stable condition. Patient given choice to go via ambulance or personal car, patient and spouse state prefers own car."

Review of physician's order record, dated 3/5/11 at 23:30 revealed the following information:
Diagnosis: IUP(Intra Uterine Pregnancy) at 40 weeks and one day, previous C/S in labor. "Discharge from triage to go directly to Hospital SJ per patient request" signed by Staff #51.

Review of progress notes dated 3/5/11 23:30 documented the following information: "Spoke with Resident at Hospital SJ, Attending on call will not do vaginal birth after cesarean section (VBAC). Patient will need repeat C/S even if in labor and desires VBAC."

Staff #51 documented that she spoke to the Obstetrician on call at Hospital EH regarding the patient and the physician said he would offer a repeat C/S to the patient since VBAC is not available at Hospital EH. She went to discuss with patient, patient and spouse had already left Labor and Delivery unit.

Discharge instructions were given to the patient to go directly to Hospital SJ Labor and Delivery by the Triage Nurse. Called Hospital SJ Labor and Delivery to let them know that the patient was enroute.

Review of Discharge Summary dated 3/5/11 at 23:10 documented that Discharge provider was Staff #51. Patient's condition was stable, she was discharged to: Other
Teaching instruction given to patient and spouse, instructions understood. "Patient was to go directly to Hospital SJ, is per patient request."

There was no documentation that the facility staff obtained an acceptance from Hospital SJ. There was no documentation of risk or benefit of patient going to SJ Hospital. Staff did not document that patient was informed of the potential risk of leaving the hospital by personal vehicle.

Review of the facility 's policy # LL.EM.005 dated 3/2008 described as EMTALA documented the following information:

"Purpose: To establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment or an appropriate transfer for the individual as required by Emergency Medical Treatment and Active Labor Act (EMTALA)."

Section IV documented that the evaluation of the patient is "an on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until the individual is stabilized or appropriately transferred."

Further review of the facility policy revealed policy titled "Transfer of OB Patients to Other Facilities" # 707- 060 presented at the time of the investigation documents the following information at section A, B, C, E and H:

High-risk patients will be transferred to a facility providing a higher level of care.
Purpose: to provide patients with appropriate level of care.
Procedure sections A, B, C, E and H gave the following information:
(A) Attending physician must make arrangement for transfer of patients and write an order.
(B) Nursing is to arrange with admitting office of the receiving facility.
(C) Nursing will contact receiving unit and give verbal report.
(E) Nursing will arrange transport by ambulance or helicopter
(H) Complete a Memorandum of transfer to go with the patient.

There was no indication that these protocols were followed.

During a telephone interview on 3/29/11 at 2:00 pm with Patient #1, she stated she was discharged and instructed to go directly to Hospital SJ. She was given instructions and the Nurse walked her to the waiting room where her husband was waiting. She walked to her car which was parked outside.

When asked by the Surveyor if she was offered an ambulance Patient #1 stated the Nurse told her she could go in an ambulance or in her personal car and since her car was there she decided to go by car. No one told her there was a risk to go by private car.

Hospital SJ

Review of Obstetric Triage Record at Hospital SJ revealed Patient #1 was admitted on [DATE] at eight (8) minutes after midnight. Reason for admission was documented as labor with contractions at a pain scale of 7/10 (10 being the most severe pain). She was examined and there was documentation that the Impression was: Active labor, with plan for a repeat cesarean section.

Interview on 3/17/11 at 8:15 am with the Quality Director at Hospital SJ, she stated the Nurse Midwife at Hospital EH called Hospital SJ on 3/5/11 at 11:30 pm, requesting to transfer Patient #1 for a vaginal delivery after cesarean section. The physician informed the Nurse Midwife that Hospital SJ would only do a repeat C/S for the patient and since Hospital EH offers the same service and the patient is already there and in labor they should keep and treat the patient.

During a telephone interview on 3/31/11 with Physician T from Hospital SJ, he stated it was a complete surprise to him when the patient showed up in her own private vehicle in labor from Hospital EH. According to Physician T, Hospital EH did not call them and said the patient was on her way.