Tucson Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 43788 Based on review of hospital documents, on-call schedules, medical records, and interviews, it was determined the hospital failed to provide, within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the emergency medical condition of one individual (Patient #1, 1 of 20 patient records sampled), who had sought emergency examination and treatment for leaking amniotic fluid during pregnancy at 17 weeks gestation. Findings include: Review of the hospital policy titled,”Emergency Medical Screen and Patient Transfers (EMTALA) 2022,” document AB-01-05, effective 11/15/2022, revealed: “...Tucson Medical Center will follow all rules and regulations as set forth by EMTALA to ensure that all EMTALA Patients are treated equally and appropriately based on their emergency medical needs and/or conditions, including psychiatric and behavioral health conditions (including substance abuse)...The Screening Practitioner will provide a MSE, on all EMTALA Patients seeking treatment, to determine if an EMC exists. If the MSE determines that an EMC exists, treatment will be provided to stabilize the EMTALA Patient within the capabilities of TMC or arrange for transfer to another medical facility if the benefits of such transfer outweigh the risks. ... MEDICAL SCREENING. 3.1. The screening shall be conducted by a Screening Practitioner to determine whether the EMTALA Patient has an EMC. Based on the results of the EMC, the following procedures are applicable: 3.2. If, in the professional judgment of the Screening Practitioner, the EMTALA Patient does not have an EMC, the basis for this determination shall be fully and clearly documented in the medical record... 3.3. A patient without an EMC may be referred for further non-emergency medical treatment either through the hospital's facilities, through a private physician, through appropriate community healthcare facilities, or at any other facility, and/or the patient may be discharged ...PREGNANT PATIENTS. 5.1. At a minimum, the MSE for a pregnant EMTALA Patient should include the following: Ongoing evaluation of fetal heart tones; Regularity and duration of uterine contractions; Fetal position and station; and Cervical dilation and status of the membranes, including whether the membranes are intact, leaking or ruptured... 5.2. All pregnant EMTALA Patients at less than 20 weeks gestation will be evaluated in the Emergency Department regardless of complaint and follow the Emergency Department screening procedure ... 6.1. TMC will only perform Abortions on EMTALA patients when, on the basis of the physician’s good faith clinical judgment, it is necessary to stabilize the EMTALA patient (including an abortion necessary to stabilize a patient in order to avoid or prevent placing the health of the woman in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part). Stabilizing treatment shall be provided to prevent material deterioration of the patient ’ s condition, and TMC shall not delay stabilizing treatment.” Review of Patient #1’s ED medical record dated 02/26/2025 revealed that Patient #1 arrived at the emergency department on 02/26/2025 at 1930 informing staff that she was 17 weeks pregnant and noticed clear vaginal discharge for approximately 1 hour after “a ‘gushing’ feeling” and that she “then went to the bathroom and saw that she was ‘leaking clear fluid.’ “ The hospital’s treating ED physician documented “ultrasound c/w [consistent with] premature rupture of membranes with oligohydramnios” (too little amniotic fluid around the fetus) and documented her diagnosis as “premature rupture of membranes in second trimester, unspecified duration to onset of labor.” The hospital’s ED physician documented that after discussion with a named OB/GYN physician, “Termination is an option.” The medical record did not contain separate documentation by the OB/GYN physician or further documentation that the on-call OB/GYN physician had come to the ED or assessed Patient #1. The medical record revealed no documentation that stabilizing treatment for PPROM was provided, nor that any options for stabilizing treatment were discussed with or offered to Patient #1 prior to her being discharged on 02/27/2025 at 0034. Cross-refer to tag A-2407.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 43788 Based on review of hospital documents, on-call schedules, medical records, and interviews, it was determined the hospital failed to provide, within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the emergency medical condition of one individual (Patient #1, 1 of 20 patient records sampled), who had sought emergency examination and treatment for leaking amniotic fluid during pregnancy at 17 weeks gestation. This deficient practice poses a risk to the health and safety of patients if emergency care and stabilizing treatment are not provided to patients determined to have an emergency medical condition. Findings include: Cross-refer to tag A-2400 for hospital policy titled, “Emergency Medical Screen and Patient Transfers (EMTALA) 2022,” document AB-01-05, effective 11/15/2022,” incorporated here by reference. Review of the hospital policy titled, “Tucson Medical Center Medical Staff Policy On Call Physician Responsibilities”, document 4872-3176-7903, approved 05/16/2024, revealed: “...III. On Call Physician Requirements. 1. Emergency Department (“ED”) Call. (a) All On Call Physicians are required to comply with Emergency Medical Treatment and Active [sic] Labor Act (“EMTALA”) requirements. (b) When requested by an ED Physician ...to see an ED patient requiring specialty assessment, the On Call Physician will come to the ED, assess the patient, and assist in determining the appropriate plan of care ...If the On Call Physician believes it is outside his or her current practice to care for the patient, at the request of the ED Practitioner, the patient must still be assessed and a note describing the reason for the On Call Physician’s inability to care for the patient must be placed in the patient record ... VI. Follow Up. An On-Call Physician is responsible for the continuing care of a patient through the episode that created the emergency medical condition, including one follow- up office visit provided in a timely manner related to that episode ...” Review of the hospital policy titled,”Rupture of Membranes”, document WS-03-23, effective 01/09/2024, revealed the policy “References” to include “American College of Obstetricians and Gynecologists. (2020) ACOG practice bulletin: Prelabor Rupture of Membranes Number 217 (Replaces Practice bulletin Number 172, January 2018). Washington, DC.” Review of a document provided by the hospital titled “ACOG PRACTICE BULLETIN Clinical Management Guidelines ...Prelabor Rupture of Membranes,” number 217, dated March 2020 and published by the American College of Obstetricians and Gynecologists, revealed: “...Membrane rupture before labor that occurs before 37 weeks of gestation is referred to as ‘preterm prelabor rupture of membranes’ [preterm PROM or PPROM ...Membrane rupture may occur for a variety of reasons. Although membrane rupture at term can result from a normal physiologic weakening of the membranes combined with shearing forces created by uterine contractions, preterm PROM can result from a wide array of pathologic [abnormal] mechanisms ...Intraamniotic infection has been shown to be commonly associated with preterm PROM, especially at earlier gestational ages ... Among women with preterm PROM, clinically evident intraamniotic infection occurs in 15-35% of cases ...The incidence of infection is higher at earlier gestational ages ...Abruptio placentae [premature detachment of the placenta from the uterus, often associated with life-threatening bleeding] complicates 2-5% of pregnancies with preterm PROM ...Sepsis [life-threatening immune system response to infection], intraventricular hemorrhage [bleeding inside the brain of the fetus], and necrotizing enterocolitis [a life-threatening intestinal condition in newborns] also are associated with prematurity ...One center found that that 14% of women with periviable PROM experienced significant maternal morbidity, including sepsis, transfusion, hemorrhage [severe bleeding], infection, acute renal injury [kidney failure] ...Life-threatening maternal infection may complicate expectant management [ ‘watchful waiting’ ] of periviable PROM. Maternal sepsis is reported in approximately 1-5% of cases ...,and isolated maternal deaths due to infection have been reported in this setting...Periviable (Less than 23-24 weeks of gestation) ...Expectant management of preterm PROM generally consists of hospital admission with periodic assessment for infection, abruptio placentae, umbilical cord compression, fetal well-being, and labor...Intraamniotic infection in preterm pregnancy requires a high index of suspicion because early signs and symptoms may be subtle. In the absence of fever, other clinical criteria, such as abdominal or fundal [uterus] tenderness and maternal or fetal tachycardia [fast heart rate] have variable sensitivity and specificity for diagnosing infection...Leukocyte [white blood cell] counts and other markers of inflammation have not been proved to be useful ...Expectant management of periviable PROM has significant maternal risks that are important to monitor carefully when choosing outpatient management. Such outpatient management should involve frequent temperature evaluations, clear counseling on how to monitor for the signs and symptoms of abnormalities (eg, abdominal pain, vaginal bleeding, abnormal discharge), and frequent evaluations by a health care provider ...Women presenting with PROM before neonatal viability should be counseled regarding the risks and benefits of expectant management versus immediate delivery. Counseling should include a realistic appraisal of neonatal outcomes...Immediate delivery (termination of pregnancy by induction of labor or dilation and evaluation) and expectant management should be offered. Physicians should provide patients with the most current and accurate information possible.” Review of Patient #1’s ED medical record dated 02/26/2025 revealed that Patient #1 arrived at the hospital’s emergency department on 02/26/2025 at 1930. Documentation by an ED registered nurse (RN) at 2025 included, “Reason for visit (subjective account): pt [patient] states that within the last couple of hours she had a ’ gushing ’ feeling. Pt then went to the bathroom and saw that she was ‘leaking a clear fluid ’ Pt states that she has been here within the last couple of days for other concerns with her pregnancy but tonight she started leaking the clear fluid. Came in right after this happened ...Pt is 17 weeks pregnant, G1P0” (indicating her first pregnancy). Documentation by the hospital’s treating ED physician on 02/27/2025 at 0005 included, “Patient presents with Pregnancy Problem. RN Triage Note read and considered ...17 weeks presents to the ED for evaluation of leaking fluid from her vagina. She states this began earlier in the day. She has been urinating more so initially thought it was urine. She has had leaking when not urinating as well. She was admitted from 2/24-2/25 for hyperemesis gravidarum [severe vomiting associated with pregnancy]. She is followed by midwives ... Review of Systems ...Genitourinary: Positive for vaginal discharge ... Radiologist interpretations ordered & reviewed: US OB [obstetrical ultrasound] 12-19.6 Weeks ...Final Result 1. Live intrauterine pregnancy, 17 weeks 0 days. 2.Oligohydramnios [too little amniotic fluid around the fetus] concerning for premature rupture of membranes ... ED Course/Discussion: She presents to the ED for evaluation of vaginal discharge, leaking of fluids. Labs revealed an hCG quantitative level of 78,867 [normal pregnancy hormone level for this gestational age], ...normal white blood cell count, hemoglobin... Ultrasound c/w [consistent with] premature rupture of membranes with oligohydramnios, FHT 170s [fetal heart tones, normal 120-160]... Discussed with ob [obstetrician/gynecologist] hospitalist Dr. [name] and no intervention possible. Pelvic rest recommended. She was advised to follow up with her midwife ... 12:05 AM Discussed with ob Dr. [same name]- leak could seal. Termination is an option. Usually just watch. Pelvic rest. No bed rest needed but could help. Rec f/u with MFM [Maternal Fetal Medicine, the subspeciality of obstetrics and gynecology concerned with high-risk pregnancy]... Diagnosis Premature rupture of membranes in second trimester, unspecified duration to onset of labor 17 weeks gestation of pregnancy. Plan/Disposition: Dischg [discharge]- Home.” The medical record reflected that on 02/27/2025 at 0022, the hospital provided Patient #1 with written instructions that included, “PPROM is serious. It creates health dangers for the mother and the baby. These include a higher risk of: Needing to have a cesarean delivery...[,] a serious infection for both the mother and the baby[,] a lung problem called respiratory distress syndrome in the baby[,] the baby ’ s lungs not growing as much as normal[,] bleeding in the baby ’ s brain[, and] the baby dying. PPROM needs medical care right away.” The medical record reflected that Patient #1 was discharged on 02/27/2025 at 0034. The medical record did not contain separate documentation by the named OB/GYN physician or further documentation that the on-call OB/GYN physician had come to the ED or assessed Patient #1. The medical record revealed no documentation that stabilizing treatment for PPROM was provided, nor that any options for stabilizing treatment were discussed with or offered to Patient #1. The medical record did not contain any evidence that at the time of her discharge from the ED, the hospital had provided any treatment of Patient #1’s condition to assure, within reasonable medical probability, that no material deterioration of the condition was likely. During an interview conducted 05/07/2025 and 05/08/2025, the hospital’s Chief Medical Officer characterized the hospital’s expected protocol for managing PPROM as “follow ACOG [American College of Obstetricians and Gynecologists] guidelines.” The hospital provided a copy of those guidelines, titled “ACOG PRACTICE BULLETIN Clinical Management Guidelines ...Prelabor Rupture of Membranes,” number 217, dated March, 2020 and published by the American College of Obstetricians and Gynecologists. Review of the hospital’s on-call schedule for OB/GYN physicians revealed that a different physician was listed as on-call during Patient #1’s presentation than the physician named in Patient #1’s medical records. Patient #1’s medical record did not contain documentation that the on-call OB/GYN physician was ever contacted or involved in her care. A follow-up interview with the hospital’s Chief Medical Officer on 09/12/2025 confirmed that the OB/GYN physician named in Patient #1’s medical record was an OB hospitalist who was in-house covering Labor and Delivery on 02/26/2025, but the OB/GYN on-call for the ED was a different physician, whose name was correctly listed on the on-call schedule. During an interview conducted 09/12/2025 with the hospital’s ED physician named in Patient #1’s medical record, the physician verified that they recalled caring for Patient #1 on 02/26/2025-02/27/2025. The physician stated that when a pregnant patient comes to the ED, the procedure is to contact the patient ’ s OB provider, but Patient #1’s provider was a midwife, and they generally did not contact midwives. They stated they had the ED unit clerk call the OB physician on-call for a consult but did not recall the name of the OB physician. The ED physician recalled the OB physician saying “the leak could possibly spontaneously close on its own but because of the age of the fetus, the probable outcome was not good.” The ED physician stated they often do not request on-call providers to come into the ED to examine patients at night. During an interview conducted 09/11/2025 with the OB/GYN physician named in Patient #1’s medical record, the physician described their role within the hospital as an OB hospitalist who cares for “any pregnant woman of 20 weeks gestation or older who presents to the Labor and Delivery unit at TMC or the OB Triage area in the Labor and Delivery area.” She stated that if a pregnant woman under 20 weeks gestation presents to the OB triage area, the OB hospitalist will evaluate the patient and will either continue treating the patient, if indicated, or transfer the patient to the main emergency department for further care. She clarified that if a pregnant woman under 20 weeks gestation presents to the ED, the patient is evaluated by the ED provider and if a pregnancy issue is identified, the ED provider is to call the OB/GYN physician on-call, not the OB hospitalist for consultation. She recalled being on-duty in the Labor and Delivery unit as the OB hospitalist on the evening of 02/26/2025 and receiving a telephone call from the ED physician, who said there was a pregnant woman of 17 weeks gestation with premature rupture of membranes. She stated she informed the ED physician of the need to contact the OB/GYN on-call for the ED, since the patient was under 20 weeks gestation. She stated she did “offer some brief education” to the ED physician regarding premature rupture of membranes, such as “the outlook is not good, usually there is fetal demise, sometimes the leak will repair and reseal on its own.” She stated she did not consider the phone call a consultation, as it was a brief phone call, and she had informed the ED physician that she needed to call the OB/GYN on-call for guidance and to come in to evaluate the patient. She stated when the call ended, she was “under the impression that the ED provider was going to contact the OB/GYN on-call for consultation.” During an interview conducted 05/01/2025 with Patient #1, she recalled that on the evening of 02/26/2025, she felt a “gush of fluid vaginally” and went to the Tucson Medical Center ED for evaluation. Patient #1 stated that, following her ultrasound evaluation, the ED physician informed her that “the baby still had a strong heartbeat” and that the ED physician had called an OB doctor who told the ED physician over the phone that “since there was some amniotic fluid left that there was a possibility that the amniotic fluid would stop leaking and the leak would repair on its own.” She was not informed of the risks of PPROM or any treatment options and was told to “go home and rest, that at this point there wasn’t anything that could be done, that they had to wait and see what happened.” Patient #1 said that an OB doctor did not examine or speak to her and confirmed that she was not presented with any options for stabilizing treatment while at Tucson Medical Center. Patient #1 stated she was discharged home on 02/27/2025 at 0034. She stated she called her midwife the morning of 02/27/2025 and informed her that she had been in the ED at TMC the night before and that she had been leaking amniotic fluid. The midwife informed her to go to [name of Hospital B] and that the midwife would arrange for an OB doctor there to examine her. Patient #1 stated she presented to the ED at Hospital B on 02/27/2025 around 1015 and was seen by an OB provider, still leaking fluid with position changes. She stated another ultrasound was done around noon on 02/27/2025, which “showed low fluid around the baby, but the baby still had a heartbeat.” She said the OB provider told her “that the baby wasn’t going to survive” and was given the option to have an induction of labor. She chose induction and stated she delivered a stillborn baby on 02/28/2025 at 0253. Review of medical records from Hospital B revealed that Patient #1 presented there on 02/27/2025 at 1016 and evaluated in the ED by an on-call OB/GYN physician. She was transferred to the OB Triage unit at or around 2021, where she underwent extensive counseling of the risks and benefits of each option to stabilize previable PPROM, “including expectant management with antibiotics, D&E [dilation and evacuation, surgical emptying of the uterus through the cervix], and induction of labor.” Patient #1 elected to undergo induction of labor and delivered a stillborn infant at 0253 on February 28, 2025.”