This special report, Deprived of Care: When ERs Break the Law, is an investigation by WebMD and Georgia Health News. Here’s a link to Part 1, Lives lost amid ER violations, investigation finds

Jamie Larson had just been wheeled into a room at Sutter Roseville Medical Center in Roseville, CA, after the birth of her first child when a nurse popped in to tell her, “It’s a boy!”

Larson, a 30-year-old schoolteacher, had a more somber question on her mind.

“Is he alive?”

Larson had just given birth to him in the hospital parking lot. His birth came less than an hour after nurses at the same hospital had assured her that her back pain was from a urinary tract infection and sent her home.

Larson’s son was born at 24 weeks and 5 days — well before a  40-week pregnancy and on the cusp of the age when the most advanced neonatal medicine can keep a premature infant alive.

At the time, a doctor explained to Larson that babies born this early have a 20% to 30% chance of survival, but only if they are delivered under ideal circumstances. Her son was not.

Larson’s case was cited by federal authorities in a 2016 report as a violation of the Emergency Medical Treatment and Labor Act, or EMTALA. It was one of at least 72 different violations committed by hospitals over a 27-month period ending in March 2018 involving the care of women who were pregnant or in active labor, according to federal records obtained through the Freedom of Information Act. The cases represent about 8% of the total number of violations investigated by the Centers for Medicare & Medicaid Services (CMS) over that period.

Lack of birthing services

Under federal law, labor is considered a medical emergency. Any hospital that accepts payments from federal programs such as Medicare or Medicaid is required to take care of patients who are in labor when they come to the ER, regardless of their ability to pay for that care.  Because virtually all hospitals accept these payments, nearly all are covered by the law.

The law received its name, in part, because of a woman in labor in California who was refused treatment by two private hospitals even though medical tests showed her baby was in distress. The hospitals mistakenly thought she was uninsured.  By the time she arrived at the public hospital, where doctors rushed to perform an emergency C-section, her baby had died.

Despite their special protection for pregnancy under the 1986 law, the records show that pregnant women remain vulnerable to violations, though not for all the same reasons.

Now, instead of not treating patients who don’t have insurance, a practice called patient dumping, some hospitals turn away women in labor because they no longer have dedicated obstetrical units or enough staff who are properly trained to handle pregnancy and labor complications.

A study published in 2017 in the journal Health Affairs found that between 1985 and 2002, 760 U.S. hospitals shuttered their obstetrical units. That trend has continued. The study also found that 9% of rural counties lost their OB services between 2004 and 2014. Counties with more black residents had nearly five times higher odds of losing their OB services than counties with more white residents.

“We know that those closures have continued. If we were to do an update, it would look I think even more dire than it does now,” says study author Carrie Henning-Smith, PhD, assistant professor in the division of health policy and management at the University of Minnesota School of Public Health in Minneapolis.

“Today, fewer than half of all rural counties have an obstetrical unit in a hospital,” Henning-Smith says.

‘We do not deal with babies’

Federal records show that the erosion of birthing services has created confusion about how to respond when a woman in labor arrives at the ER.

That’s what happened on July 11, 2017, when a man pulled up outside the 98-bed emergency room at Leonard J. Chabert Medical Center in Houma, LA. His wife was 36 weeks pregnant and bleeding.  He requested a wheelchair from a nurse in the ER. Instead he was told, “We cannot help you here. We do not deal with babies,” according to a federal investigation report.  The incident, captured by a hospital security camera, shows him driving away moments later.  The report didn’t include names for privacy reasons and doesn’t document what happened to the couple or their baby.

In an emailed statement, Leonard J. Chabert Medical Center declined to comment on the specifics of this violation, citing patient privacy laws.

“Our physicians, leaders, nurses and employees participate regularly in ongoing education and training to ensure that they live our vision of changing and saving lives each day,” the statement says.

On Dec. 12, 2016, a man approached a nurse in the Deer Lodge Medical Center in Deer Lodge, MT. He told them that his girlfriend was in labor. A federal investigation report says that a nurse at the 16-bed hospital told him they didn’t deliver babies and suggested the couple travel to a hospital in either Anaconda or Butte, 27 or 39 miles away, respectively. The man drove away. His girlfriend was almost fully dilated by the time she reached the next hospital and delivered the baby immediately after arrival.

Tony Pfaff, chief executive officer of Deer Lodge Medical Center, pushed back against that description of events. “It’s not remotely accurate,” he says.

He says the man approached a nurse and a doctor in the ER. The man asked if the hospital delivered babies. They told him that they didn’t, but offered to evaluate his girlfriend. He asked which hospitals in the area did deliver babies. They told him, and he drove away. Pfaff says his staff never saw the woman in labor.

When asked if the hospital had tried to correct the version of events in the investigation report, Pfaff says “No.” “We just decided to take our beating and move on because you can’t win” against the federal government, he says.

In response to the violation, Pfaff says the hospital has given its staff additional EMTALA training. They also created a way to log patients and their representatives who come into the ER but refuse treatment or leave without being seen. Those two actions satisfied CMS, he says. Pfaff says if the same thing happened again today, they’ve instructed their staff to try to be a little more aggressive in trying to see the patient. He says the hospital knows its obligations under the law.

“We’ve delivered babies in our ER before. It’s unusual, but we do it,” he says.

CMS officials say their EMTALA investigations are thorough and include interviews with hospital officials, physicians, and nurses and reviews of medical records. If a violation is found, hospitals must submit a plan of correction, where they can address any objections or issues they have with the federal findings. Hospitals can also appeal any fines levied for violations, CMS says.

Federal investigators cited both Deer Lodge and Leonard J. Chabert Medical Center for failing to do proper medical screening exams for the women, which are required by law.

An ER’s obligations under EMTALA

Howie Mell, MD, an emergency physician in Chicago and spokesperson for the American College of Emergency Physicians, says no hospital should be confused about its obligations under the law.

“First of all, you can’t turn anyone away who asks for help, and who may either have an emergency medical condition or may be in active labor,” he says.

Even if a hospital doesn’t have a dedicated obstetrical unit, Mell says all board-certified emergency physicians are trained in residency to deliver babies.

That doesn’t mean all ER doctors are trained to do C-sections or to manage birth complications, Mell says. He says there are patients who may need a higher level of care, and in those cases, the hospital’s obligation is to stabilize and safely transfer a woman to a hospital where those services are available.

Those transfers, even when done correctly, can be fraught with problems.

On July 22, 2017, a woman went to the Methodist Hospital for Surgery in Addison, TX, with cramps and vaginal bleeding. She was in her second trimester of pregnancy.  The doctor who examined her decided her case was more complicated than their hospital could handle. She called another hospital, which agreed to accept her.

Before they could load her on the ambulance, however, she delivered a preterm baby that was not crying and barely moving.  As a further complication, the doctor did not deliver the placenta, an organ which supplies blood to the baby during pregnancy, an essential next step to stop bleeding and lower the mother’s chances of infection. The baby was placed on the mother’s chest and both of them were loaded into an ambulance. The two of them were left in the hospital’s ambulance bay for 100 minutes — almost 2 hours — according to the federal inspection report.

When the pair finally arrived at the receiving hospital, medical records documented that the mother was covered in blood, with 8 inches of umbilical cord protruding from her vagina. The baby was dead.  Investigators cited the hospital for not stabilizing the patients before the transfer and for not providing an appropriate transfer. The investigation report doesn’t say what later happened to the mother.

Methodist Hospital for Surgery did not respond to a request for comment on this violation.

Missing labor

In Jamie Larson’s case, a federal investigation found that when she arrived at Sutter Roseville Medical Center, she was seen by two nurses. One was still in orientation. The other was her supervisor. Doctors at that hospital relied on the nurses’ assessment to determine if a pregnant patient was in labor, according to the federal report.

The nurses hooked Larson up to a fetal monitor, a machine that monitors the baby’s heart rate and the mother’s uterine contractions. The monitor didn’t show anything out of the ordinary.

They didn’t perform a cervical exam, although Larson told the nurses she was bleeding. They also failed to take into account the fact that she was having regular painful cramps in her back that were getting closer and closer together. If a woman complains of contractions that don’t show up on a monitor, the nurses are supposed to move the monitor.

According to CMS guidelines, the nurses’ exam didn’t meet the federal criteria of an adequate medical screening exam. An exam for a pregnant woman should include a check of fetal heart tones, measuring contractions, determining the baby’s position and where it is in the birth canal, checking the woman’s cervix to see if it is dilated, and seeing if her water has broken.

Instead, the nurses asked her for a urine sample. Larson says that on her way back from the bathroom, she was having trouble walking. The pain was so bad, she asked for a wheelchair.

The results of the test came back positive for a urinary tract infection. Larson questioned the test result, telling the nurses that she wasn’t having any other symptoms of a UTI and that she’d had false positive results on the same test twice before.

Larson says the hospital sent her home with a prescription for antibiotics. Meanwhile, the pain was getting worse. Larson and her husband drove home, about 12 minutes away. On the way home, she vomited in the car. She remembers thinking, “Well, maybe this is a normal part of a UTI.”

Larson was pregnant with her first child and says she had no idea what to make of what was going on with her body. She had scheduled birthing classes, but they were still a month away.

Her husband was worried, though, and wondered whether he should stay with her or go get her prescription filled.

She told him to go to the pharmacy. On the way out the door, he called his mother and told her something was wrong. Could she please come stay with Jamie?  She was there within minutes.

“She said as soon as she walked in the door, she could tell I was in labor.”

The next time Larson went to the bathroom, she saw blood. Larson told her mother-in-law they needed to go back to the hospital. They jumped in her Toyota truck and called Larson’s husband, telling him to meet them there.

Larson’s contractions were constant, an intense period of labor known as transition. She felt a pop.

“I thought, ‘I’m having a miscarriage, this baby is dying.’”

As they pulled into the hospital parking lot, Larson says she felt enormous pressure on her abdomen. She tried to get out of the truck but got stuck, perched on the edge of the seat, with one foot on the floorboard.

Her mother-in-law flagged down a man in the parking lot who was getting into his car to leave.

“We think she’s having a baby!” she yelled.

The man was an obstetrician-gynecologist.   He quickly walked back into the hospital and came back out with a cadre of nurses and a wheelchair for Larson.

She saw them come out of the hospital and yelled, “Run!”

She could feel the baby sliding out of her body. He was caught by her underwear and yoga pants.  She couldn’t bring herself to look.

A nurse arrived and in one motion yanked her pants down and caught the baby.

“They pulled him out and he wasn’t moving. I thought he was dead. He was just so, so tiny,” Larson says.

The nurse scooped the baby up and ran with him back into the hospital.

Babies born at 24 weeks have immature lungs and lack a slippery chemical called surfactant in their lungs. This can lead to trouble breathing and potentially fatal lung damage if they are not treated and given oxygen.

They wheeled Larson back into the hospital. She was sobbing hysterically and covered in blood.

After what felt like an eternity, a nurse brought the baby in just briefly to say hello. It was the first time Larson had gotten a look at him. It was a short visit. They whisked the baby away to a different hospital for specialized neonatal care.

As they delivered the placenta and cleaned her up, Larson remembers the room was very, very quiet.

Her husband, who never cries, collapsed sobbing by her bed. He had pulled up to the hospital just in time to see the whole thing.

After its review of her case, CMS determined that none of the eight labor and delivery nurses at Sutter Roseville Medical Center were qualified to do a medical screening exam, a situation that placed patients in immediate jeopardy. A finding of immediate jeopardy is a serious federal violation that requires a hospital to submit and follow a plan of correction or risk losing federal funding.

Larson’s son spent 138 days in the neonatal intensive care unit. Even after he came home, he was fragile. Larson asked that his name not be used to protect his privacy.

Larson says she had to take 2 years off of work to care for him because they couldn’t put him in a normal daycare — his weak immune system put him at greater risk of getting sick. She now volunteers with the Aly and Izy Foundation, which supports parents of premature infants.

She spent a year in therapy being treated for post-traumatic stress.

In response to a request for comment, Erin Shaw, a spokesperson for Sutter Roseville Medical Center, emailed the following statement:

“Sutter Roseville Medical Center strives to provide the best in patient care. We took CMS’ findings seriously, and quickly identified opportunities for improvement and implemented actions to address them. Patient privacy laws prevent us from discussing the particulars of this situation.”

Larson says she hopes the nurses at the hospital will get more training and listen more carefully to their patients.

“I didn’t know what my rights were as a patient and how to advocate for myself,” Larson says. “I wish I had been better prepared.”

Brenda Goodman is a staff writer for WebMD.  Her work has appeared in The New York Times, Scientific American, Psychology Today, The Boston Globe, Self, Shape, Parade, U.S. News and World Report, and Atlanta Magazine. She has a master’s degree in science and environmental reporting from New York University.

Your rights in the ER

The Emergency Medical Treatment and Labor Act, or EMTALA, guarantees a certain level of medical care to anyone who comes to an emergency department that accepts payments from Medicare or Medicaid.

Some labor and delivery units and psychiatric hospitals are also governed by EMTALA.

Under the law enacted in 1986, emergency departments must:

• Offer patients a timely and appropriate medical screening exam.
• This exam is different from triage, in which a nurse or other provider takes vital signs to decide the order in which to see patients.
• Unlike with triage, a health care professional with a certain level of expertise — typically a doctor, advanced practice nurse, or physician assistant — must do the medical screening.
• Medical screening exams are done to find out the cause of a patient’s symptoms. They cannot be delayed or denied in order to ask about a patient’s ability to pay.
• Medical screening exams must make use of all the hospital’s relevant resources, for example, lab tests or CT scans.

Over the last 10 years, the most frequent EMTALA violation by hospitals was the failure to do an adequate medical screening exam.

• Stabilize patients who have emergency medical conditions.

Failure to offer stabilizing treatment was the fourth most common EMTALA violation over the last 10 years.

• If a hospital can’t stabilize a patient, it is required to arrange an appropriate transfer to another facility, including:
• Treatment to lessen the risks of transfer
• Getting consent from the receiving hospital to accept the transfer
• Ensuring the transfer involves qualified personnel and transportation (an ambulance)

Failure to do an appropriate transfer was the second most common way hospitals have violated EMTALA over the last 10 years.

• Keep appropriate records on patients, including a central log of who came to the ER and what happened to them.

Failure to keep this log was the third most common EMTALA violation over the last 10 years.

• Post signs in the ER letting people know about these rights.
• Keep a list of on-call doctors who can see patients in case of an emergency.
• Accept appropriate transfers from other hospitals if the receiving facility has special abilities or is able to care for an incoming patient.
• Not punish any hospital employee who reports a violation.
• Report any improperly transferred patients it receives within 72 hours.

SOURCES:

Centers for Medicare and Medicaid Services, State Operations Manual, Appendix V, Interpretive Guidelines, Responsibilities of Medicare Participating Hospitals in Emergency Cases, 7-16-10.

Editor’s note: If you have experienced what you think may be an EMTALA violation, you can contact your regional Centers for Medicare & Medicaid Services office. You can find your local office from the CMS.gov website. Anyone can report a violation anonymously. The CMS office will need details to properly investigate your claim. Health officials will investigate your claim, but no more involvement is likely necessary on your part, CMS officials say.

How we reported this story

For this 8-month investigation, WebMD and Georgia Health News filed a Freedom of Information Act request to the Centers for Medicare & Medicaid Services for a list of all EMTALA violations by hospitals across the U.S. between January 2008 and March 2018.

The list detailed the number of violations, which hospitals had committed them, when they happened, and the nature of the offenses.

There were 4,341 violations by 1,682 hospitals. That’s almost a third of about 5,500 registered hospitals in the United States, according to the American Hospital Association.

We partnered with the geographic information systems company Esri to map this data and analyze it in different ways. That analysis revealed that smaller hospitals — those less than 100 beds — were more likely to have an EMTALA violation. We used the American Hospital Directory for bed size data.

Because we wanted to understand more about what was behind these violations, we also requested the investigation reports for the most recent 27 months of violations. These reports included full details on 874 EMTALA violations with more than 1,400 pages of documentation.

We used the facts from these investigation reports, which do not include names of patients and other details, to help us find patients and families that were affected by these violations. In some cases, we found police reports, medical records, and, in one instance, a 911 call to give more details, and we did interviews with family members and medical personnel.

We welcome questions or feedback at bgoodman@webmd.net and amiller@georgiahealthnews.com.

Valarie Basheda and Aaron Gould Sheinin contributed to the reporting.

Sources for ‘Pregnant Women’ article:

Jamie Larson, Citrus Heights, CA.

Freedom of Information Act Request, Centers for Medicare & Medicaid Services, Filed March 2018.

Carrie Henning-Smith, PhD, assistant professor, division of health policy and management, University of Minnesota School of Public Health, Minneapolis.

Emailed statement, Leonard J. Chabert Medical Center, Houma, LA.

Tony Pfaff, chief executive officer, Deer Lodge Medical Center, Deer Lodge, MT.

Howie Mell, MD, spokesperson, American College of Emergency Physicians, Chicago.

Centers for Medicare & Medicaid Services: “State Operations Manual, Appendix V—Interpretive Guidelines, Accessed November 20, 2018.”

Erin Shaw, spokesperson, Sutter Roseville Medical Center, Roseville, CA.