HospitalInspections.org

Based on interview, policy review and record review, the hospital failed to stabilize one patient (#5) of 31 Emergency Department (ED) records reviewed from August 2022 through October 2022, within the hospital's capacity and capability, when the patient presented to the ED on 08/02/22 and 08/03/22 seeking care for an Emergency Medical Condition (EMC). This failed practice had the potential to cause harm to all patients who presented to the ED with similar pregnancy-related EMCs, and there continues to be an immediate risk of harm for current and future patients unless immediate corrective action is taken. The hospital's average monthly census over the past six months was 3,061.

Findings Included:

Review of hospital policy # 247302 titled "EMTALA" with an effective date 2/1/2003, last revised 8/2001 showed that:
- All individuals that come to a dedicated ED of the hospital or elsewhere on hospital property, requesting treatment or examination for any medical condition, will receive an appropriate medical screening examination (MSE).
- The MSE will be conducted by the hospital's qualified medical personnel and if an EMC exists the individual will receive necessary stabilizing treatment or an appropriate transfer.
- The purpose of the MSE was to determine if an individual was experiencing an EMC.
- An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment of bodily function.
- If, after evaluation of a patient, it is determined that the patient has an EMC the hospital will provide such treatment as may be required to stabilize the EMC within the capabilities of the staff and facilities available, or provide appropriate transfer of the patient to another medical facility, with the capacity and capability to provide appropriate medical treatment of the EMC.
-If a patient withdraws his or her request for examination or treatment or decides to leave prior to being seen ... the ED staff member will: (1) encourage the patient to receive further medical examination and treatment ... (2) inform the patient of the benefits of the examination and treatment ... (3) If a patient finally refuses emergency treatment, the appropriate 'Leaving Against Medical Advice' or 'Leaving Without Treatment' form shall be completed and signed by the patient. If the patient refuses to sign the form, a description of risks discussed and of the examination and/or treatment that was refused shall be documented.

Review of the hospital's policy titled, "Care of the Obstetrical Patients, Full-Term," last revised 01/2022 showed that:
- All obstetrical patients shall be triaged upon arrival to the ED with determination of due date or gestational status, ruptured or intact placental membranes and name of patient's current Obstetrician. The ED and Labor Department flowsheet would be utilized to facilitate the appropriate clinical pathway for the patient.
- Patient registration into the Birthing Center (BC) will be completed for those patients routed directly into the LD care areas.
- The BC and Women's/Children services staff, on behalf of the Emergency/Trauma Center will provide the MSE and interventions and stabilization utilizing all necessary and available resources of the health system for those patients routed to and admitted to the LD.

Review of Patient #5's medical record, dated 08/02/22, showed she was a woman of advanced maternal age (higher risks associated with pregnancy when maternal age > 35 years) who was 17 weeks and 5 days gestational age (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days). She had a past medical history of a miscarriage in the first trimester of pregnancy; deep vein thrombosis (DVT, the formation of a blood clot in a blood vessel that was deep under the skin); history of a complex abdominal surgery; history of nicotine dependence; and a recent tooth infection treated with antibiotics. The patient's physician had previously written her a prescription for an anticoagulant (medication to prevent blood clots) to help treat her DVT, but the patient had not yet started the prescription. She presented to the Obstetrics (OB, branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) unit on 08/02/22 at 9:28 AM at the request of Staff D, Obstetrician/Gynecologist (OB/GYN, a specialty physician focused on women's health and delivering babies), as she was experiencing vaginal bleeding, leaking of amniotic fluid (the clear liquid that surrounds the baby in the uterus during pregnancy, loss of amniotic fluid can cause complications to the baby, such as birth defects) and abdominal cramping.

At 9:35 AM Staff I, Registered Nurse's, (RN) documentation showed that Patient #5 was placed in observation status in the Birthing Center. At 9:50 AM, the OB nurse documented blood noted on the pad the RN placed on the patient's bed. At 9:45 AM the Nitrazine test was positive (nitrazine paper is used to detect the presence of amniotic fluid). At 10:40 AM, a portable bedside ultrasound was performed. Staff D, OB/GYN physician documented the fetal heart tones were 153. A "formal ultrasound" performed at 11:24 AM showed the estimated fetal age was 17 weeks, 6 days gestation; the estimated fetal weight was 210 grams (0 lbs, 7 oz), and the amniotic fluid index (AFI) (method for measuring the amount of amniotic fluid) was 0%. Staff D diagnosed preterm premature rupture of membranes (PPROM) "confirmed by gross pooling of fluid in [vaginal] vault of bloody fluid, ferning (a confirmatory test for ruptured membranes), bedside US [ultrasound] and formal US confirming AFI of zero." "Patient understands that the fetus is not viable at this gestation outside of the uterus. She expressed concern of infection with ruptured membranes. Discussed that unless delivery becomes emergent, we are unable (sic) help her deliver due to current state law while fetus has a heartbeat, even thought (sic) the fetus is not viable."

Staff F, Maternal Fetal Medicine Specialist (MFM, a specialty physician focused on the care of women having complicated or high-risk pregnancies) consulted with Patient #5. Staff F counseled Patient #5 regarding the maternal and fetal risks of previable (not considered sufficiently developed to survive outside the uterus) preterm premature rupture of membranes (PPROM, when the water breaks before the 37th week of pregnancy) at this gestational age and given the PPROM, the patient's chances of continuing to carry the fetus to gestational age, with potential survival were extremely low. Specific maternal risks were discussed that included risks of maternal thrombosis given her history of DVT, infection/sepsis, severe blood loss, hysterotomy (surgical procedure that involves making an incision in the uterus to remove uterine contents), hysterectomy (surgical removal of the uterus) and mortality (death). Staff F explained the specific fetal/obstetric risks that included previable or preterm birth, limb contractures, pulmonary hypoplasia, intrauterine or neonatal and rupture of membranes that she did not anticipate a prolonged latency (the period of time until birth), and that chance of fetal survival was zero at this gestational age. The likelihood of latency to a gestational age with potential fetal survival was extremely low. Staff F documented she discussed the patient's vaginal bleeding, visual cervical dilation (opening of the cervix [the lower, narrow end of the uterus that forms a canal between the uterus and vagina]) of one centimeter (cm, unit of measure), cramping, and rupture of membranes. Documentation in the medical record showed the patient's vital signs were temperature of 98.4 degrees Fahrenheit, respiratory rate of 18, blood pressure of 106/63, heart rate 64, and oxygen saturation of 95%. Fetal heart tones (FHT) were present with a fetal heart rate of 153. The patient's lab results showed a white blood count (WBC, the number of white cells [infection-fighting cells] in the blood) result of 8.9 (normal range 4.5 to 11.0).

Staff F documented describing the treatment options as including medically intervening to aid the process of her inevitable miscarriage, and when the patient requested the physician to medically assist by inducing labor, Staff F documented "we discussed that the current Missouri law (188.015.7 RSMo) supercedes (sic) our medical judgement, and the MO law language states that we cannot intervene in the setting of a pregnancy with positive fetal heart motion unless there is a 'medical emergency'. She is currently medically stable with normal vitals, normal WBC/Hgb, vaginal bleeding is present but not heavy. Therefore contrary to the most appropriate management based (sic) my medical opinion, due to the legal language of MO law, we are unable to offer induction of labor at this time." The patient was given the option to travel to a different state with more permissive laws or to remain at the hospital for observation to monitor for indications of spontaneous labor or to see if she developed the Missouri definition of a "medical emergency." Staff F documented that "We discussed that awaiting a medical emergency may put her at further risk for maternal mortality, hysterotomy, hysterectomy" and that the patient chose to stay for observation because she was "unable to afford travel." The patient requested discharge later that day, electing to drive to a hospital whom she believed could augment or induce labor.

The two physicians, Staff D OB/GYN and Staff F MFM, documented similar medical decision making and discussed with patient # 5 that they were unable to help her deliver due to their interpretation of current state law, because the fetus had fetal heart tones, even though the fetus was not viable.

The serious risks of deterioration in patient # 5's health and bodily function as a result of PPROM, as noted and specifically enumerated by Staff F in the medical record, were consistent with the hospital's policy # 247302 which defined an EMC (emergency medical condition) as a "medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment of bodily function." However, inconsistent with the hospital's policy to stabilize a patient's EMC, patient # 5 was discharged on 08/02/22 at 4:49 PM with only precautions and a warning about the risks of waiting to intervene but without treatment to stabilize her EMC. There was not documentation in the medical record that the hospital secured the patient's written informed refusal of further medical examination and/or treatment prior to discharge.

Review of Patient #5's medical record from Hospital B (not located in the State of Missouri) showed the patient presented to the ED on 08/02/22 at 11:27 PM with for PPROM at 17 weeks six days gestation and reported having two large "gushes" of fluid earlier that morning with some vaginal bleeding throughout the day. Physical examination revealed visual cervical dilation of one cm, with a small clot at the cervical opening, anhydramnios (absence of amniotic fluid), WBC of 10.1. Patient educated regarding chorioamnionitis (chorio, acute inflammation of the membranes and fetal portion [chorion] of the placenta typically due to bacterial infection in patients whose membranes have ruptured) and "how quickly she could become ill" and that if she experienced symptoms to report back to her local hospital. The patient was discharged home on 08/03/23 at 1:29 AM.

Review of a second medical record showed that Patient #5 returned to the hospital on 08/03/22 at 9:35 PM, seeking care for PPROM, nonviable (not able to develop, grow or survive) fetus, gestational age of 17 weeks. Patient #5 was evaluated in the ED by Staff N, ED Physician, at 9:50 PM. Staff N documented that the patient's membranes had ruptured on 08/02/22 and that the pregnancy was not viable; the patient had seen Staff D, OB/GYN earlier on 08/03/22 around 11:00 AM and was told that she had cervical dilation of four cm. The patient continued to report pelvic pressure. She was placed in observation status in the Birthing Center on 08/03/22 at 11:43 PM with reported continued leaking of fluid but denied vaginal bleeding or abdominal cramping, just "overall aching" of the abdomen. Lab results showed a WBC count of 10.9. Patient reported to nursing staff that her abdomen was "achy" on 08/04/22 at 12:42 AM with Staff G, OB/GYN, notified and requested that the patient stay overnight if she was agreeable. Patient was given Tylenol for pain and an antianxiety medication. At 8:24 AM Staff G documented that she provided the patient education on the risks of PPROM for both the patient and the fetus, risks of possible placental abruption (when the placenta detaches from the uterus causing bleeding) and possible infection and signs of chorioamnionitis. The patient's medical record also indicated that the patient was exhibiting psychological distress associated with the situation and expressed that she perceived financial barriers to seeking further care on an outpatient basis.

Staff G, OB/GYN, ordered a consult with a neonatologist (a specialty physician focused on the care of newborn babies, sick babies, and premature babies) at Patient 5's request. Staff G documented the patient was given the option to stay in the hospital but the patient wished to go home but wanted to talk with the neonatologist before she was discharged.

Staff H, Neonatologist, documented that he consulted with Patient # 5 on 08/04/22 at 12:12 PM. Staff H discussed the prognosis of an extremely premature infant and educated the patient on the viability statistics for a baby at different gestational ages and the complications that PPROM adds to the statistics.

Discharge documentation by Staff G, OB/GYN on 08/04/22 at 12:29 PM showed the patient was "18 weeks pregnant, desires discharge to home, CBC (complete blood count) normal, VSS (vital signs stable), no signs of chorio[amnionitis], abruption, [or] labor," neonatology consult completed, "Patient may be discharge (sic) to home. Symptoms of above discussed in depth and patient knows to return." Nursing staff provided patient #5 with instructions to contact her physician if she developed signs of infection, and noted her departure time was 12:38 PM.

The medical record did not contain evidence that staff obtained the patient's written informed refusal of further medical examination and/or treatment to stabilize her emergency medical condition as defined in hospital policy # 247302.

Based on interview, policy review and record review, the hospital failed to stabilize one patient (#5) of 31 Emergency Department (ED) records reviewed from August 2022 through October 2022, within the hospital's capacity and capability, when the patient presented to the ED on 08/02/22 and 08/03/22 seeking care for an Emergency Medical Condition (EMC). This failed practice had the potential to cause harm to all patients who presented to the ED with similar pregnancy-related EMCs, and there continues to be an immediate risk of harm for current and future patients unless immediate corrective action is taken. The hospital's average monthly census over the past six months was 3,061.

Findings included:

Review of the hospital's policy title, "EMTALA," dated 08/2022 showed that:
- All individuals that come to a dedicated ED of the hospital or elsewhere on hospital property, requesting treatment or examination for any medical condition, will receive an appropriate medical screening examination (MSE).
- The MSE will be conducted by the hospital's qualified medical personnel and if an EMC exists the individual will receive necessary stabilizing treatment or an appropriate transfer.
- The purpose of the MSE was to determine if an individual was experiencing an EMC.
-An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment of bodily function.
- If, after evaluation of a patient, it is determined that the patient has an EMC the hospital will provide such treatment as may be required to stabilize the EMC within the capabilities of the staff and facilities available, or provide appropriate transfer of the patient to another medical facility, with the capacity and capability to provide appropriate medical treatment of the EMC.
-If a patient withdraws his or her request for examination or treatment or decides to leave prior to being seen ... the ED staff member will: (1) encourage the patient to receive further medical examination and treatment ... (2) inform the patient of the benefits of the examination and treatment ... (3) If a patient finally refuses emergency treatment, the appropriate 'Leaving Against Medical Advice' or 'Leaving Without Treatment' form shall be completed and signed by the patient. If the patient refuses to sign the form, a description of risks discussed and of the examination and/or treatment that was refused shall be documented.

Review of the hospital's policy titled, "Care of the Obstetrical Patients, Full-Term," last revised 01/2022 showed that:
- All obstetrical patients shall be triaged upon arrival to the ED with determination of due date or gestational status, ruptured or intact placental membranes and name of patient's current Obstetrician. The ED and Labor Department flowsheet would be utilized to facilitate the appropriate clinical pathway for the patient.
- Patient registration into the Birthing Center (BC) will be completed for those patients routed directly into the LD care areas.
- The BC and Women's/Children services staff, on behalf of the Emergency/Trauma Center will provide the MSE and interventions and stabilization utilizing all necessary and available resources of the health system for those patients routed to and admitted to the LD.

Review of Patient #5's medical record, dated 08/02/22, showed she was a woman of advanced maternal age (higher risks associated with pregnancy when maternal age > 35 years) who was 17 weeks and 5 days gestational age (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days). She had a past medical history of a miscarriage in the first trimester of pregnancy; deep vein thrombosis (DVT, the formation of a blood clot in a blood vessel that was deep under the skin); history of a complex abdominal surgery; history of nicotine dependence; and a recent tooth infection treated with antibiotics. The patient's physician had previously written her a prescription for an anticoagulant (medication to prevent blood clots) to help treat her DVT, but the patient had not yet started the prescription. She presented to the Obstetrics (OB, branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) unit on 08/02/22 at 9:28 AM at the request of Staff D, Obstetrician/Gynecologist (OB/GYN, a specialty physician focused on women's health and delivering babies), as she was experiencing vaginal bleeding, leaking of amniotic fluid (the clear liquid that surrounds the baby in the uterus during pregnancy, loss of amniotic fluid can cause complications to the baby, such as birth defects) and abdominal cramping.

At 9:35 AM Staff I, Registered Nurse's, (RN) documentation showed that Patient #5 was placed in observation status in the Birthing Center. At 9:50 AM, the OB nurse documented blood noted on the pad the RN placed on the patient's bed. At 9:45 AM the Nitrazine test was positive (nitrazine paper is used to detect the presence of amniotic fluid). At 10:40 AM, a portable bedside ultrasound was performed. Staff D, OB/GYN physician documented the fetal heart tones were 153. A "formal ultrasound" performed at 11:24 AM showed the estimated fetal age was 17 weeks, 6 days gestation; the estimated fetal weight was 210 grams (0 lbs, 7 oz), and the amniotic fluid index (AFI) (method for measuring the amount of amniotic fluid) was 0%. Staff D diagnosed preterm premature rupture of membranes (PPROM) "confirmed by gross pooling of fluid in [vaginal] vault of bloody fluid, ferning (a confirmatory test for ruptured membranes), bedside US [ultrasound] and formal US confirming AFI of zero." "Patient understands that the fetus is not viable at this gestation outside of the uterus. She expressed concern of infection with ruptured membranes. Discussed that unless delivery becomes emergent, we are unable (sic) help her deliver due to current state law while fetus has a heartbeat, even thought (sic) the fetus is not viable."

Staff F, Maternal Fetal Medicine Specialist (MFM, a specialty physician focused on the care of women having complicated or high-risk pregnancies) consulted with Patient #5. Staff F counseled Patient #5 regarding the maternal and fetal risks of previable (not considered sufficiently developed to survive outside the uterus) preterm premature rupture of membranes (PPROM, when the water breaks before the 37th week of pregnancy) at this gestational age and given the PPROM, the patient's chances of continuing to carry the fetus to gestational age, with potential survival were extremely low. Specific maternal risks were discussed that included risks of maternal thrombosis given her history of DVT, infection/sepsis, severe blood loss, hysterotomy (surgical procedure that involves making an incision in the uterus to remove uterine contents), hysterectomy (surgical removal of the uterus) and mortality (death). Staff F explained the specific fetal/obstetric risks that included previable or preterm birth, limb contractures, pulmonary hypoplasia, intrauterine or neonatal and rupture of membranes that she did not anticipate a prolonged latency (the period of time until birth), and that chance of fetal survival was zero at this gestational age. The likelihood of latency to a gestational age with potential fetal survival was extremely low. Staff F documented she discussed the patient's vaginal bleeding, visual cervical dilation (opening of the cervix [the lower, narrow end of the uterus that forms a canal between the uterus and vagina]) of one centimeter (cm, unit of measure), cramping, and rupture of membranes. Documentation in the medical record showed the patient's vital signs were temperature of 98.4 degrees Fahrenheit, respiratory rate of 18, blood pressure of 106/63, heart rate 64, and oxygen saturation of 95%. Fetal heart tones (FHT) were present with a fetal heart rate of 153. The patient's lab results showed a white blood count (WBC, the number of white cells [infection-fighting cells] in the blood) result of 8.9 (normal range 4.5 to 11.0).

Staff F documented describing the treatment options as including medically intervening to aid the process of her inevitable miscarriage, and when the patient requested the physician to medically assist by inducing labor, Staff F documented "we discussed that the current Missouri law (188.015.7 RSMo) supercedes (sic) our medical judgement, and the MO law language states that we cannot intervene in the setting of a pregnancy with positive fetal heart motion unless there is a 'medical emergency'. She is currently medically stable with normal vitals, normal WBC/Hgb, vaginal bleeding is present but not heavy. Therefore contrary to the most appropriate management based (sic) my medical opinion, due to the legal language of MO law, we are unable to offer induction of labor at this time." The patient was given the option to travel to a different state with more permissive laws or to remain at the hospital for observation to monitor for indications of spontaneous labor or to see if she developed the Missouri definition of a "medical emergency." Staff F documented that "We discussed that awaiting a medical emergency may put her at further risk for maternal mortality, hysterotomy, hysterectomy" and that the patient chose to stay for observation because she was "unable to afford travel." The patient requested discharge later that day, electing to drive to a hospital whom she believed could augment or induce labor.

The two physicians, Staff D OB/GYN and Staff F MFM, documented similar medical decision making and discussed with patient # 5 that they were unable to help her deliver due to their interpretation of current state law, because the fetus had fetal heart tones, even though the fetus was not viable.

The serious risks of deterioration in patient # 5's health and bodily function as a result of PPROM, as noted and specifically enumerated by Staff F in the medical record, were consistent with the hospital's policy # 247302 which defined an EMC (emergency medical condition) as a "medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment of bodily function." However, inconsistent with the hospital's policy to stabilize a patient's EMC, patient # 5 was discharged on 08/02/22 at 4:49 PM with only precautions and a warning about the risks of waiting to intervene but without treatment to stabilize her EMC. There was not documentation in the medical record that the hospital secured the patient's written informed refusal of further medical examination and/or treatment prior to discharge.

Review of Patient #5's medical record from Hospital B (not located in the State of Missouri) showed the patient presented to the ED on 08/02/22 at 11:27 PM with for PPROM at 17 weeks six days gestation and reported having two large "gushes" of fluid earlier that morning with some vaginal bleeding throughout the day. Physical examination revealed visual cervical dilation of one cm, with a small clot at the cervical opening, anhydramnios (absence of amniotic fluid), WBC of 10.1. Patient educated regarding chorioamnionitis (chorio, acute inflammation of the membranes and fetal portion [chorion] of the placenta typically due to bacterial infection in patients whose membranes have ruptured) and "how quickly she could become ill" and that if she experienced symptoms to report back to her local hospital. The patient was discharged home on 08/03/23 at 1:29 AM.

Review of a second medical record showed that Patient #5 returned to the hospital on 08/03/22 at 9:35 PM, seeking care for PPROM, nonviable (not able to develop, grow or survive) fetus, gestational age of 17 weeks. Patient #5 was evaluated in the ED by Staff N, ED Physician, at 9:50 PM. Staff N documented that the patient's membranes had ruptured on 08/02/22 and that the pregnancy was not viable; the patient had seen Staff D, OB/GYN earlier on 08/03/22 around 11:00 AM and was told that she had cervical dilation of four cm. The patient continued to report pelvic pressure. She was placed in observation status in the Birthing Center on 08/03/22 at 11:43 PM with reported continued leaking of fluid but denied vaginal bleeding or abdominal cramping, just "overall aching" of the abdomen. Lab results showed a WBC count of 10.9. Patient reported to nursing staff that her abdomen was "achy" on 08/04/22 at 12:42 AM with Staff G, OB/GYN, notified and requested that the patient stay overnight if she was agreeable. Patient was given Tylenol for pain and an antianxiety medication. At 8:24 AM Staff G documented that she provided the patient education on the risks of PPROM for both the patient and the fetus, risks of possible placental abruption (when the placenta detaches from the uterus causing bleeding) and possible infection and signs of chorioamnionitis. The patient's medical record also indicated that the patient was exhibiting psychological distress associated with the situation and expressed that she perceived financial barriers to seeking further care on an outpatient basis.

Staff G, OB/GYN, ordered a consult with a neonatologist (a specialty physician focused on the care of newborn babies, sick babies, and premature babies) at Patient 5's request. Staff G documented the patient was given the option to stay in the hospital but the patient wished to go home but wanted to talk with the neonatologist before she was discharged.

Staff H, Neonatologist, documented that he consulted with Patient # 5 on 08/04/22 at 12:12 PM. Staff H discussed the prognosis of an extremely premature infant and educated the patient on the viability statistics for a baby at different gestational ages and the complications that PPROM adds to the statistics.

Discharge documentation by Staff G, OB/GYN on 08/04/22 at 12:29 PM showed the patient was "18 weeks pregnant, desires discharge to home, CBC (complete blood count) normal, VSS (vital signs stable), no signs of chorio[amnionitis], abruption, [or] labor," neonatology consult completed, "Patient may be discharge (sic) to home. Symptoms of above discussed in depth and patient knows to return." Nursing staff provided patient #5 with instructions to contact her physician if she developed signs of infection, and noted her departure time was 12:38 PM.

The medical record did not contain evidence that staff obtained the patient's written informed refusal of further medical examination and/or treatment to stabilize her emergency medical condition as defined in hospital policy # 247302.

During an interview on 10/24/22 at 4:00 PM, Staff G, OB/GYN, stated that:
- She saw Patient #5 on her second visit to the hospital on 08/03/22.
- She reviewed the risks of infection, bleeding, fetal death, maternal health, with infection being the greatest risk.
- The patient requested to speak to a neonatologist.
- The patient was admitted to BC under observation status on 08/03/22.

During an interview on 10/25/22 at 10:25 AM, Staff H, Neonatology Director, stated that he saw Patient #5 for a consult regarding a nonviable fetus and PPROM. He stated that he informed the patient that survival chances for the fetus were discussed along with statistics of a baby born extremely premature. Survival prognosis for her baby were extremely low because of the prematurity and the lack of amniotic fluid.

During an interview on 10/25/22 at 4:10 PM, Staff J, OB Registered Nurse, RN, stated that she was the day nurse for Patient #5 on 08/04/22 and that she gave the patient discharge instructions about risks of infection and vaginal bleeding.

Patient # 5 presented to the hospital on two separate occasions, the first visit on 08/02/22 and the second visit on 08/03/22. In both cases, especially given the patient's risk factors, PPROM represented a medical condition where the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, and/or serious dysfunction of a bodily organ or part and, therefore, constituted an EMC. Medical record documentation reflects that physicians during both visits recognized these risks, understood that deterioration can occur rapidly and unexpectedly, and articulated this to the patient. The medical records also reflect that hospital staff understood induction of labor as the appropriate treatment to stabilize the EMC by delivering the nonviable fetus and placenta, sufficiently mitigating those risks. In this circumstance, delivery of both fetus and placenta, along with all products of conception, either by dilation and evacuation (D&E, a procedure to remove tissue from inside the uterus) or induction of labor would be required to prevent clinical deterioration. Alternative approaches, such as expectant management (observation), antibiotics, cerclage (a procedure to suture the cervix closed), and tocolysis (medications to reduce uterine muscle activity), would be insufficient to stabilize this patient's EMC. Staff F, Maternal Fetal Medicine Specialist, specifically documented the risks of observation to await the Missouri definition of "medical emergency" as including "maternal mortality, hysterotomy, [and] hysterectomy." Review of the hospital's capabilities showed that the facility and its medical staff were capable of providing stabilizing treatment but failed to do so on both visits, explicitly citing their perception of conflicting Missouri law. Consequently, during both visits, the hospital failed to stabilize Patient # 5's EMC when she presented to the hospital seeking emergency medical care for PPROM with a nonviable fetus, gestational age of 17 weeks, and discharged her without stabilizing treatment, which placed the patient at risk of material deterioration of her health and safety, spontaneous delivery outside of a healthcare setting, and bleeding, hemorrhage, infection of the uterus, sepsis, septic shock, hysterectomy, amniotic fluid embolism, venous thromboembolization (VTE) and maternal death.

Additionally, the patient's cervical dilation was 1 cm on 08/02/22 and remained at 1 cm when she sought care at Hospital B on 08/02/22 at 11:27 PM. During Patient #5's second visit on 08/03/22, Staff N, ED Physician's documentation at 9:50 PM, reflected that the patient had seen Staff D, OB/GYN at her clinic earlier that same day around 11:00 AM, with cervical dilation of four cm. The degree of cervical dilation was not re-assessed at any time during the patient's second visit on 08/03/22 - 08/04/22 to attempt to disprove that she was in labor or to determine how quickly her cervical dilation was progressing, despite the knowledge that her last cervical assessment (four cm) was approximately 10 hours, 50 minutes prior to the second ED visit. This progression implies some level of uterine activity, even if the patient didn't perceive it as contractions, which could constitute labor. Thus, the progression of cervical dilation itself and the concern for labor constitute an additional EMC on the second visit that was not stabilized prior to discharge.