HospitalInspections.org

Based on document review, record review, policy review and interview the hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate medical screening exam (MSE) and failing to provide stabilizing treatment for patients who presented to the emergency department seeking emergency medical care for an emergency medical condition (EMC). Failure to provide an appropriate MSE and appropriate transfer places patients at risk for unidentified emergency medical conditions resulting harm and injury up to an including death.


Findings Include:


Review of a document titled, "Medical Staff Rules and Regulations," Revised 09/2023, " ...Each member of the medical staff shall comply with these medical policies related to Emergency Medical Treatment and Labor Act (EMTALA) ... The Medical Screening Examination required by EMTALA may be conducted by a physician who is a member of the Health Center's active or limited active Medical Staff or other qualified medical personnel ..."


Review of a policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Screening-Treatment-Transfer and On-Call Roster Policy" revised 02/28/24 showed, " ... Stormont Vail Health ("SVH") shall comply with federal law by providing, within its capabilities, to each person who comes to the ED an appropriate medical screening examination to determine whether the individual has an emergency medical condition and to provide necessary stabilizing treatment ... Emergency Medical Condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: ...2. Serious impairment of bodily functions; or 3. Serious dysfunction of any bodily organ or part ...Hospital Property. Hospital property includes SVH's main buildings, the physical area immediately adjacent to main buildings, other areas and structures that are not strictly contiguous with the main buildings but are located within two hundred fifty (250) yards of the main buildings. This definition includes parking lots, sidewalks, and driveways, but excludes other areas or structures that are not part of SVH, such as physician offices, or other entities that participate separately under Medicare, or non-medical facilities. Medical Screening Examination. A medical screening examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists or whether a woman is in labor. It is more extensive than an initial triage assessment that determines the order in which individuals coming to the ED will be seen ... Stabilized. With respect to an emergency medical condition, stabilized means that (i) within reasonable clinical confidence, the emergency medical condition has been resolved; (ii) that no material deterioration of the condition is likely, within reasonable medical probability ...For purposes of an individual with a psychiatric condition, the individual is considered to be stabilized when he/she is no longer considered to be a threat to himself/herself or to others ...1. Medical Screening Examination. SVH shall provide a medical screening examination to each individual who comes to the ED. The extensiveness of the medical screening examination shall be based upon the medical judgment of the qualified medical personnel performing the medical screening examination. All ancillary services routinely available in the ED shall be made available to each individual who comes to the ED. 2. Individuals who come to a location other than SVH's ED. Individuals who Come to hospital property at a location other than at the ED who require a medical screening examination in accordance with Section 1 above, shall be transported or escorted to the ED for a medical screening examination and stabilizing treatment as soon as possible unless it would be more appropriate in the circumstances: to provide an examination and/or treatment in another location on the hospital's property; or to request ED personnel to come to the individual ... Individuals coming to the ED shall not be discharged without having completed a medical screening examination unless the individual or his/her legal representative refuses to consent to such examination, and the refusal is properly documented.


Review of a policy titled, "Suicide Risk Reduction - ED" Dated 07/15/20 showed, " ...Process Description: Suicide Risk Reduction Procedure for Emergency Room Patients ...Key Points 1. Patient identified as a Suicide Risk using the Columbia assessment in triage. Cycle Time 2 minutes. Reasons 1. All patients in the Emergency Room are screen for suicide risk using the Columbia ...6. Qualified staff will accompany patient from one area of the hospital to another. Cycle Time 2-3 minutes ...6. Continuous monitoring by qualified staff is required to reduce risk of harm to the patient ..."


Review of a policy titled "Suicide Prevention Patient Care Management Policy" revised 04/05/23 showed "POLICY: It is the policy of Stormont Vail Health (SVH) to take steps to identify patients who are at risk for suicide and implement strategies to provide a safe and secure environment while they are in our care. Patients who have been identified at risk will have safety measures implemented to monitor their safety ...Safety Measures: ...High Risk; High Risk and violent/aggressive a. Consider psychiatric safe room assigned ... Notify Attending Physician and Charge Nurse. PATIENT EDUCATION: 1. Education the patient on the plan of care. Include family and significant others if available and ...3. Educate patient about a safety plan to help the patient after discharge and develop the plan with the patient 4. Provide mental health resources at discharge with follow up care as indicated to include the suicide hotline. REPORTABLE CONDITIONS: clinically 1. Change in level of consciousness, behavior, speech, ability to move 2. Self-inflicted injuries 3. Openly threatening to commit suicide 4. Making passive suicidal statements "When I'm gone", statements of being a burden or feeling hopeless appropriate ...6. Sudden change in mood or behavior - sudden compliance or increased irritability/anger ...8. Isolating behaviors- refusing to talk, making dismissive statements i.e. "Whatever, I don't care, just leave me alone, doesn't matter" ...11. Concerns expressed by patient/family. DOCUMENTATION: 1. Complete the Columbia Suicide Severity Rating Scale according to department Protocol. ...7. The discharge safety plan will be completed for high risk patient prior to discharge. If completed on paper a copy will be scanned into the EMR and the original given to the patient. 8. Provide mental health resources and follow up appointments at discharge with as indicated to include the suicide hotline ...


Review of a hospital policy titled, "Restricting a Patient's Discharge" Review/Revised 4/10/23 showed, " ...POLICY / PURPOSE: The purpose of this policy is to clarify the legal standards and processes that apply when attempting to restrict a patient's discharge and to "retain" or "detain" them in order to provide healthcare services. Stormont Vail Health (SVH) strives to provide high quality care that respects the patient's right to autonomous decision-making while effectively addressing situations that may present an imminent risk of harm to the patient or others due to a serious mental health or medical condition ... POLICY STATEMENTS: A. PREVENTING A PATIENT'S DISCHARGE 1. The preventing ("detaining") of a patient from leaving a treatment facility constitutes a significant infringement and restriction on their freedoms. 2. Kansas statutes allow a treatment facility to "detain" a patient only in specific situations for "emergency observation" when the patient meets the statutory criteria for involuntary civil commitment for mental illness, which includes the presence of an imminent threat of harm to self or others. Consequently, detention often involves the use of restraints and /or seclusion. 3. The retention of a patient who lacks capacity but does not meet the statutory criteria for involuntary commitment for mental illness, involves various methods to encourage the patient to remain, including, persuasion, de-escalation, and redirection ...C. PATIENTS WITHOUT DECISIONAL CAPACITY 1. Involuntary Civil Commitment The involuntary civil commitment of a patient requires the following four criteria to be met. The patient: 1. must suffer from a mental disorder to the extent that they need immediate treatment; AND 2. lack the capacity to make an informed decision about their treatment (i.e. due to the patient's mental health disorder, demonstrate that, despite conscientious efforts at explanation, the patient cannot understand the nature and effects of their hospitalization or treatment as evidenced by an inability to weigh the possible risk and benefits and to make a decision that aligns with their values); AND 3. have a treatable mental illness other than alcohol/substance abuse, anti-social personality disorder, intellectual disability, organic personality syndrome or an organic mental disorder; AND 4. pose an imminent threat that the patient is reasonably likely to cause harm to self and/or others. The legal definition of imminent threat is that which is certain, immediate and impending vs. something that might happen or might occur in the future. When a patient meets all of the above criteria and a physician desires to initiate the involuntary civil commitment process, the physician is to consult Risk Management for review and mutual approval. Appropriate planning and personnel resources will need to be arranged due to the fact that the detention period can generally take between 48-72+ hours to complete the process and transfer the patient to an appropriate mental health institution. If approved, the physician is to place a Mental Health Order in the chart to detain the patient.4 The order should generally contain or accompany an order for restraints and/or seclusion given the presence of imminent harm involving the patient. 5 The physician must then complete a written application for emergency observation of the patient pursuant to Kansas Statute 59-2954(c) ..."


Review of the Kansas State Statute: 59-2954. Emergency observation and treatment; authority of treatment facility's procedure. (a) A treatment facility may admit and detain any person for emergency observation and treatment upon an ex parte emergency custody order issued by a district court pursuant to K.S.A. 59-2958 and amendments thereto ...(c) A treatment facility may admit and detain any person presented for emergency observation and treatment upon the written application of any individual, except that a state psychiatric hospital shall not admit and detain any such person, unless a written statement from a qualified mental health professional authorizing such admission to a state psychiatric hospital has been obtained. The application shall state: ...(3) the applicant's belief that the person may be a mentally ill person subject to involuntary commitment and because of the person's mental illness is likely to cause harm to self or others if not immediately detained; ..."


Review of a policy titled, "Visitor Occurrence Reporting" Review/Revised 05/11/23 showed, "Purpose: To support effective management of visitor accidents and incidents by assuring that such events are accurately recognized, responded to, reported, documented and evaluated to: o Assure that the immediate security, safety and information needs of visitors involved in events are met ...Definitions: Visitor Incident: Any unusual event not consistent with the routine operations of SVH that involves a visitor including, but not limited to: accidents or falls (with or without injury) ... Visitor: Any individual who is present on property owned or leased by Stormont Vail Health who is not currently registered as a patient, acting as an employee or performing assigned volunteer duties on behalf of Stormont Vail Health ...Procedure: 1. In the event of an incident that involves an accident, the highest priority is to care for the individual(s) involved ... 2. As appropriate, the individual may be offered the opportunity to be registered as a patient to receive care in the SVH ED (if emergent care is needed) ... 9. Nothing in this policy is intended to override SVH responsibilities to provide Emergency Medical Screening Exams for individuals presenting for emergency medical care. (See SVH Policy: Emergency Medical Treatment and Labor Act (EMTALA) Screening, Treatment, Transfer and On-Call Roster).


The hospital failed to ensure an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists was completed for 4 of 21 patients (Patient 1, 12, 19, and 21) who presented to the emergency department (ED) seeking emergency medical care. (Refer to tag A2406)


The hospital failed to provide stabilizing treatment for 4 of 21 patients (Patient 1, 12, 19, and 21) who presented to the emergency department seeking emergency medical care. (Refer to tag A2407)

Based on record review, policy review, document review and interview the hospital failed to provide an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists for 4 of 21 patients (Patient 1, 12, 19 and 21) who presented to the emergency department (ED) seeking emergency medical care. The hospital's failure to ensure an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which delays necessary stabilizing treatment and may lead to deterioration of the person's condition, including harm and death.


Findings Include:


Patient 1


Review of Patient 1's medical record dated 05/07/24 at 5:00 AM " ...Service(s) being requested: Client came to door asking for help. Client stated he went to crisis as he is suicidal and not safe, client shared that he had overdosed on Saturday and friends used Narcan and he overdosed on Sunday and friends used CPR [Cardiopulmonary Resuscitation]. Non-emergency ambulance called for clients welfare and will be taken to [Above Named Hospital] for evaluation. Client stated he really needs detox and treatment ...."


Review of Patient 1's "Prehospital Care Report" incident date/time 05/07/24 at 5:31 AM showed "Found ambulatory at scene of mental health facility. Staff stated that he had been released from prison last Friday and has been taking meth (methamphetamine), cocaine, fentanyl, alcohol and weed since then; Patient overdosed on Saturday and Sunday ... patient is very lethargic and stated he would like to commit suicide by a fentanyl overdose ...patient report was given and received by hospital RN ..."


Review of Patient 1's, medical record showed, a 36-year-old who presented to the Emergency Department (ED) on 05/07/24 at 6:11 AM by ambulance. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found). His chief complaint was "Pt [Patient] reports to ed [Emergency Department] with complaints of recent drug use. States he took heroin and fentanyl within the last two hours. Pt [Patient] states he was trying to commit suicide by using drugs ..." He has a history of anxiety, asthma, bipolar disorder, depression, intravenous drug abuse and Obsessive Compulsive Disorder presented with substance abuse relapse and suicidal ideation. .


Review of "Columbia Suicide Severity Rating Scale (C-SSRS)" dated 05/07/24 at 6:17 AM, showed, "1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? Yes; 2. In the past month, have you actually had any thoughts of killing yourself? Yes; 3. Have you been thinking about how you might do this? Yes. 4. Have you had these thoughts and had some intention of acting on them? Yes. 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? Yes; 6a. Was this within the past three months? Yes. Risk of Suicide High Risk."


Review of Patient 1's "ED Notes" dated 05/07/24 at 7:25 AM, written by Staff O, License Master Social Worker, LMSW showed " ...Suicide Risk/C-SSRS ...Risk of Suicide: High Risk ...Risk Factor Assessment; Suicidal and Self-Injurious Behavior: Actual suicide attempt; Describe preparatory acts: Overdose; Suicidal Ideation (Most Severe in Past Month): Suicidal intent with specific plan (2 days ago); Activating Events (Recent): Pending incarceration or homelessness; Treatment History: Not receiving treatment; Clinical Status (Recent): Highly impulsive behavior, Substance abuse or dependence ... Does the patient need a safety plan completed before discharge? Yes Pt eloped prior to safety plan completion ...Symptoms; Mood/Pt Behaviors: Irritable; Judgment: Impaired; Compliant with Prescribed Medication Regime?: Not on medication; Psychiatric Treatment History; Current Psychiatrist and/or therapist?: No.."


During an interview on 05/31/24 at 9:13 AM, Staff O, LMSW, stated that, patients who are able to keep themselves safe receive a safety plan. [Patient 1] had a suicidal attempt couple days prior; he had needles falling out of his socks and kept saying that they were insulin needles. Then he started saying he wanted to leave, calling the doctor names, and subsequently, he left against medical advice. He was denying being currently suicidal at the moment I met with him. Since he was being verbally abusive, he was escorted out by security.


Review of Patient 1's "MDM [Medical Decision Making]" dated 05/07/24 at 7:04 AM, showed that, ...Here after heroin use over the last several days. Patient reports he was kicked out of rehab housing. Attempted to go to [Community Mental Health Center] but they did not have bed for him so went up here. Patient sleepy here but arouses to voice. Remains uncooperative. Additional needles found on patient in his pockets and socks. Vital signs otherwise stable. No oxygen requirement. Discussion of potential discharge led the patient to become agitated, belligerent, yelling, and cursing at staff members. Security involved. Patient demanding his syringes be given back to him. Encouraged drug cessation. Resources were provided. Patient left with security.


During an interview on 05/29/24 at 11:28 AM, Staff H, MD (Doctor of Medicine), stated, " ...Looks like he was on, or using drugs the last couple of days and either he left or was dismissed ..." Staff H, MD, shown charting that Patient 1 was high risk for suicide and trying to commit suicide with drugs stated, "it's tricky."


Review of Patient 1's "ED Notes" dated 05/07/24 at 8:50 AM, showed, "Pt becomes verbally aggressive/abusive to staff when being woke up. Pt states he will leave. Security notified and pt escorted to door ..."


Review of "Discharge Instructions - Encounter Notes" on 05/07/24 at 8:52 AM, showed, "Avoid further drug use, follow up on resources provided."


Even though security staff escorted Patient 1 out of the ED, review of an entry titled, "ED Disposition" dated 05/07/24 at 8:57 AM, showed, "Eloped".


Review of Patient 1's medical record on 05/31/24 at 9:28 AM, Staff A, RN, Director of the Emergency Department, stated that Patient 1's disposition was incorrect and it should not be elopement since patient left with security.


Review of Patient 1's medical record failed to show that the hospital provided an adequate MSE to determine whether he had an EMC. He did not receive a medical screening examination that addressed his complaint of suicidal ideation or sufficient to determine the presence or absence of an emergency medical condition.


Review of Patient 1's [Community Behavioral Health Center] medical record dated 05/07/24 at 10:21 AM showed " ...Client is struggling with depression and wanting to die/kill himself ..." One hour and 24 minutes after being discharged out of ED from [Above Named Hospital].


Patient 12


Review of Patient 12's medical record showed, a 48-year-old male, presented to the Emergency Department (ED) on 05/17/24 at 1:02 PM by police transportation. Patient 12 was triaged at 1:49 PM with an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found.) His chief complaint was suicidal and homicidal ideation.


Review of Patient 12's "ED Triage Notes" dated 05/17/24 at 1:41 PM, written by Staff G, Registered Nurse (RN) showed, "Pt [sic] arrived with [Police Department] officer who reports that pt [sic] had called and was stating he was suicidal. Pt [sic] has abrasion to left wrist that was self-inflicted. Pt [sic] is here mumbling, and then in raised voice talking about killing someone; someone "on internet." Pt initially pacing around the waiting room. Now sitting and calm. P/w/d [pink/warm/dry]. Eupneic [normal respirations], GCS 14 [Glasgow Coma Scale indicating mild dysfunction. A normal GCS score, indicating full neurological health, is 15]."


Review of Patient 12's "ED Triage Notes" dated 05/17/24 at 1:50 PM, written by Staff G, RN showed, "Pt [sic] wants to kill wants to kill someone named [name] who we [sic] met on the internet because he disrespected him. Pt [sic] oriented x 4. Pt [sic] seems to be preoccupied with Trump winning the election and Microsoft stock winning. Pt [sic] intoxicated, reports drinking 1/2 pint today. Pt [sic] newly homeless after getting into a fight with his neighbor."


Review of Patient 12's "Columbia Suicide Severity Rating Scale (is a suicidal ideation and behavior rating scale)" dated 05/17/24 at 1:52 PM, showed, "...Risk of Suicide High Risk ..."


Review of Patient 12's "ED Notes" dated 05/17/24 at 2:36 PM, written by Staff EE, RN showed, "This RN attempts to locate patient in ED waiting room, as ED room is ready for patient. Upon looking for patient in ED waiting areas, unable to locate. Registrar reports patient left the ED. [Police Department] contacted at 1435 [2:35 PM] for welfare check, sent to voicemail, message left to return call to [phone number] in concern to welfare check needed. [Police Department] returns call at 1540 [3:40 PM], reports they will attempt to contact patient for welfare check."


During an interview on 05/29/24 at 11:44 AM, Staff G, RN stated that she works triage a lot and it is not uncommon to have a 45-to-50-minute wait before a patient is triaged. Staff G went on to state that if a patient comes in and they're suicidal or homicidal or both and cannot be placed in a room they are put in the front lobby. Staff G stated, "I did not feel the patient met the criteria for room 13 [suicide precautions room] ...The Police Department to my knowledge does not follow up so we do not know if they actually done the welfare check ..."


Patient 12 presented with a complaint of suicidal/homicidal ideation and was at risk for self harm/harm to others. He needed placement in a safe and monitored environment in the ED. However, the nurse decided that he did not meet the criteria for room 13. He was in need of a medical screening examination (MSE) to determine whether he had any other medical conditions contributing to his current psychiatric condition. It appeared that he needed a psychiatric evaluation and possible inpatient admission. Instead, Patient 12 left the ED waiting room and did not receive any medical interventions.


During an interview on 05/29/24 at 11:27 AM, Staff H, Doctor of Medicine (MD) stated, " ...we will not hold a patient at this facility, we were told by the attorney general we cannot hold the patient regardless if they are suicidal or homicidal ..."


During an interview on 05/30/24 at 3:13 PM, Staff AA, RN stated that we don't notify security if we place a patient in the waiting room that is suicidal or homicidal due to confidentiality.


Patient 19


Review of Patient 19's medical record showed, a 22-year-old, presented to the ED on 10/29/23 at 1:56 PM by private vehicle with mother, and two other family members. Patient 19 was triaged at an ESI 2.


Review of Patient 19's "ED Triage Notes" showed, "Pt [Patient] to triage accompanied by mother seeking inpatient tx [treatment] for pt [sic] who is manic (showing wild, apparently deranged, excitement and energy). Per mother, pt [sic] took LSD (Lysergic acid diethylamide a potent hallucinogen drug that alters person perception of reality) previous Tuesday and has had suicidal tendencies since that time. Pt [sic] refused to let RN [registered nurse] place ID [identification] bracelet at this time as she states, " I died last Tuesday". Pt [sic] not answering additional questions at this time."


Review of Patient 19's "ED Triage Notes" dated 10/29/23 at 2:02 PM, showed, "Pt [sic] delayed in answering questions in triage. Pt [sic] states she knows where she is and "her worst fears have come true."


Review of Patient 19's "Columbia Suicide Severity Rating Scale" dated 10/29/23 at 2:06 PM, "...Risk of Suicide High Risk ..."


Review of Patient 19's "ED Provider Notes" dated 10/29/23 at 2:23 PM, showed, "Chief Complaint; Patient presents with Altered Mental Status ...Physical Exam ... Neurological: Mental Status: She is alert. ...Psychiatric: Comments: Patient agitated ... Medical Decision Making: 21-year-old female here today with parent and concern for manic behavior. Patient has a history of bipolar apparently. Parent also relating that patient took LSD several days ago. Patient speaking loudly in an agitated manner. She is approaching hitting room occupants including other patients and their family members. She occasionally is shouting and raising her voice. She does not appear to be physically aggressive. No evidence of trauma. She is speaking clearly without difficulty. Her movement is purposeful. Does not appear to be any focal or unilateral neurological deficits. Patient does not appear to be short of breath. She has good muscle tone. Patient was offered multiple times to be taken to a room for evaluation and treatment. Patient not responding to questions. After a brief moment of being somewhat calm she began to get agitated again. Again she declined to answer or respond to multiple offers of being roomed, evaluated, and treated. Given the lack of cooperation, patient was then discharged. She was escorted from the waiting room by security. Parent is with patient. Nothing in patient interaction indicating that patient does not have capacity to make her own decisions. Discussed at length with parent that we could not force patient to be evaluated ..."


During an interview on 05/29/24 at 2:01 PM, Staff P, Advanced Practice Registered Nurse (APRN), stated, " ...We don't do MSE's in the waiting room but if a patient is being uncooperative or not answering questions, it's difficult to see if they are alert and orientated. If unable to get history from patient, we would try to get history from family. Safety would be our number one concern. My guidelines are that we are not to physically force any patient into a room per the hospital policy. The attorney general came and told us that we can't force people to be treated against their will. The social worker does the heavy lifting on the patients to see if they need to be admitted..."


Review of "Discharge Instructions - Encounter Notes" dated 10/29/23 at 2:33 PM, showed, "Follow up with your doctor in two days. Return to the emergency room as needed."


Review of "ED Notes" dated 10/29/23 at 2:35 PM, showed, "Pt [Patient] escorted out with the assistance of security. Unable to provide discharge instructions."


Review of "ED Notes" dated 10/29/23 at 2:45 PM, written by Staff Y, LMSW (Licensed Master Social Worker) showed, "Patient brought to ED by her mother. ED SW [Social Worker] contacted by triage nurse that patient was agitated and screaming in the ED lobby. ED SW went to lobby and patient had been taken to the parking lot by security due to her disruptive behavior in the lobby. ED SW went to the parking where patient was with her mother and two friends. Also present was security officers and charge nurse. Patient was making statements such as, "I have been saved." And "God is with me." Patient's mother had paperwork stating she is patient's legal guardian. ED provider had seen patient earlier and patient refused to be roomed for assessment. Patient was discharged and told if she returned, [Local Police Department] would be called for criminal trespass by security. Recommendation was for patient to go to [Community Behavioral Health Care 1]. Patient left with her mother and two friends. ED social worker left a message on the [Community Behavioral Health Care 1] Crisis Intake message line of patient being brought by her mother."


Review of document titled "IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION 12" electronically filled 2022, Dec, 08 AM 11:46, showed, "LETTERS OF GUARDIANSHIP; [Patient 19's Mother], having been appointed and qualified of [Patient 19], an adult with an impairment in need of a guardian, is granted Letter of Guardianship with full power and authority as provided by law, including all powers and duties of a guardian set out in K.S.A. 59-3075 and 59-3077. IT IS SO ORDERED ...Honorable [Judge 1], District Judge ..."


During an interview on 05/30/24 at 12:30 PM, Staff Y, LMSW, stated, "...The patient was psychotic she had not been taking medication screaming, "I'm god" and "I have been saved" they were instructed to come to ED for involuntary hold by EMS. [Hospital 1] would not put a hold on her, she was out in the parking lot because of her disruptive behavior and was told she could not come back because of disruptive behavior. The mother had paperwork in her hand, but I did not look at paperwork she was holding. I don't know why she wasn't let back in; we do let other patients that are disruptive stay all the time..."


Review of hospital document titled "Patient Relations" dated 01/02/24 at 10:53 AM, showed, " ...Patient name: [Patient 19] ...Admission Date: Oct 29, 2023, 1:56 PM ...Narrative description: Patient mother has submitted survey feedback regarding daughter care that she received [sic] from her visit in the ER on 10/29/2023: ...I am [Patient 19's mother] the mother and guardian for [Patient 19]. I know my daughter's condition Bipolar I Manic is complicated. I showed up in the ER told the front desk people that ...I have guardianship paperwork ... Once she was in your ER ... the doctor came in the waiting room and said no he wouldn't help her. She was pushed out of the door by 3 security officers, and 2 to 3 nurse staff. Then they shoved her in my car and didn't give us any direction on what we should do ... "Doctor didn't even ask me about her condition just that he would not treat her ..."


During an interview on 05/30/24 at 2:51 PM, Patient 19's mother (F1) stated that the hospital kicked us out before Patient 19 was seen for being manic and trying to hurt herself. She stated that she had guardianship paperwork and asked if there was a room to put her in because while the nurses were questioning, she started to grab at staff and all the hospital things. She stated that the staff said no and told her that she would need to wait in the waiting room. F1 stated that she told staff that it was not going to be good to have her in the waiting room ... F1 stated that Patient 19 started screaming at the top of her lungs and messing with other people not 2 seconds later. She stated the doctor came in and said that they could not treat her, and they need to go to the Community Behavioral Health Care 1. F1 stated that they were thrown out and it took six people to pick her up and throw her out of the hospital. She stated that the hospital told her is she came back it would be trespassing. F1 stated that a lady cop said that she was trying to be nice, but that Patient 19 just couldn't come there anymore. F1 stated that she then drove to a hospital in Kansas City on 10/29/24, and Patient 19 was admitted.


During an interview on 05/30/24 at 3:44 PM, Staff T, Security Guard stated "I was approached by her mother, she had exhausted all of her resources and was looking for help. The patient was very agitated and mother stated she would respond to gentle talking. The doctor asked in waiting room if she wanted help and would not respond to doctor. The patient would yell and verbally attack her mother. She was asked to leave and wouldn't leave, then she threw herself on the ground, so I put her in a body wrap to keep harming herself. I told her that she still needed to get help after I put her in the car."


During an interview on 05/30/24 at 12:09 PM, Staff U, Armed Security, stated that Patient 19 was having a mental health crisis. Her mom had wanted her to stay and be treated. The patient was talking loudly and having abnormal conversations with other waiting room patients and throwing herself on the ground. Staff U spoke to the mother about patient options which is jail with law enforcement or hospitals. Staff U went on to state that for mental health patients they will be asked to leave, be arrested and released. Then return to the hospital to get help and get trespassed again so it's a circle, due to a lack funding and we tend to pass them around."


During an interview on 05/31/24 at 9:28 AM Staff A, RN Director of Emergency Department, stated that, if a patient states that they want to harm self or others, the doctor would decide if the patient had capacity if they did not have capacity. Then doctor would do ex parte order to hold the patient. If provided with guardianship paperwork we would copy paperwork and put into the chart ..."


Review of Patient 19's medical record came into the ED demonstrating psychiatric symptoms and behaviors. She needed placement in the ED in a safe and monitored environment. Patient 19 needed a psychiatric evaluation and, if necessary, inpatient psychiatric admission/treatment. Patient 19 needed an MSE to determine if she had any other current medical conditions contributing to her psychiatric condition. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 19. The hospital failed to provide Patient 19 an MSE for a condition manifesting itself by acute psychiatric disturbances and/or symptoms of substance abuse. Further review of the medical record failed to show F1 was allowed to make medical decisions for Patient 19 as her legal guardian.


Review of Patient 19's hospital 3 medical recorded dated 10/29/23 at 3:31 PM, 56 minutes after being dismissed from hospital 1, showed Patient 19 presented to the ED in Kansas City with bipolar mood disorder type 1 (Period of abnormally elevated or irritable mood and high energy, accompanied by abnormal behavior that disrupts life) with psychotic symptoms (experiencing delusions, hallucinations or confused and disturbed thoughts).


Patient 21


Review of a document titled, "EMS Patient Care Report" showed, Patient 21, a 45-year-old male with Altered Level of Consciousness and Chest Pain Suspected Cardiac on 05/15/24 at 5:35 PM.


Review of a document titled, "EMS Patient Care Report" showed, "[Ambulance Service] dispatched for a sick at a skilled nursing facility non-emergent. [Ambulance Service] went en route as [Ambulance Service] was passing by sidewalk in front of [Hospital 1] ambulance bay as a small group of bystanders and law enforcement officers were frantically waving [Ambulance Service] down to stop as there was an unconscious male lying on the side walk. [Ambulance Service] pulled over and diverted to that call. Bystanders reported that they found the patient like this, unknown when or how he fell. Patient had emesis noted on the ground next to his mouth. Airway patient and breathing adequately. Patient woke to painful stimulation. Patient reported that he had chest pain and was attempting to get to [Hospital 1]. Patient also reported that he has a history of seizures. [Ambulance Service] and fire crew assisted patient onto cot via sheet lift and secured with all seatbelts. Secured in ambulance. Vital signs on scene were stable. IV attempt made on scene. Patient denied any injuries or pain other than pain in his chest. Patient refused aspirin as he felt like he could not take it. [Ambulance Service] went enroute to hospital. Patient became more alert en route but remained confused. Vital signs remained stable with no further changes in assessment findings. Diverted from [Hospital 1] to [Hospital 2] ..."


Review of a document titled, "Incident Report" dated 05/15/24 at 5:30 PM showed, " ...At around 1730 [5:30 PM] hours on the above date, [Staff CC, Security] was dispatched to the area of 10th and Washburn on a man down. As [Staff CC] was entering the area, [Staff CC] was advised that the subject was on the sidewalk near the southern [sic] lower helipad. On scene, there were two unkknown [sic] employees and a bystander trying to assist. [Staff CC] noted that male subject was on his left side, vomiting. One of the unknown employees was a medical staff member. Sternum rubs were given with little response from the subject. [Staff CC] began to search the subject and found two long knives and a expandable baton [sic]. [The Ambulance Service] was dispatched. A [Police Department] officer arrived and assisted with trying to obtain the subject's name. The medical staff employee found an alert bracelet that stated that he had heart issues. [Ambulance Service] arrive, along with [Fire Department] and they took over care of the patient. [Staff CC] alerted the ER officers that this subject was on the way there and that he had weapons on his person. The weapons were placed in the subjects backpack. [Staff CC] cleared at this time ..."


During an interview on 05/29/24 at 5:17 PM, Staff V, Paramedic, stated, "this is a very odd case because the patient was on the sidewalk closest to [Hospital 1] ...the patient was right there by the fence of the helicopter pad ...[The Ambulance Service] happened to be driving by and see everyone flagging [The Ambulance Service] down ...when [The Ambulance Service] arrived [Hospital 1] security and a woman in scrubs were attending to [Patient 21] ...called to give a radio report to [Hospital 1] but [Hospital 1] said divert we told [Hospital 1] [Patient 21] was trying to get into their Emergency Department and [Hospital 1] stated again please divert ..."


During an interview on 05/30/24 at 4:31 PM, Staff CC, Security, stated that there was a man down on the sidewalk by the lower helicopter pad with vomit on the ground laying on his left side and [Hospital 1] dispatch called [The Ambulance Service]. Staff CC went on to state, "...I heard on the radio that [The Ambulance Service] got rerouted to [Hospital 2] even though they were literally right there at the ambulance bay ..."


During an interview on 05/31/24 at 9:28 AM, Staff A, RN Director of Emergency Department, stated, " ...if you are on our property and need medical attention, we would see you regardless if on diversion ..."

The hospital failed to provide an MSE to Patient 21 who was on hospital property and whose appearance or behavior showed a need for an examination or treatment to determine whether he had an emergency medical condition. Patient 21 was found down next to the ambulance bay with decreased responsiveness and later complaining of chest pain. Patient 21 did not receive an MSE from the hospital. The hospital failed to do a history and physical, an EKG, any labs, or any imaging studies to determine whether the patient had an EMC. Since Patient 19 did not receive an appropriate MSE, they could not determine whether the patient needed any cardiac stabilizing treatments like aspirin, cardiac consultation, cardiac catheterization, and/or hospitalization. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 21 and he subsequently received care at Hospital 2.

Based on record review, document review and interview the hospital failed to provide stabilizing treatment for 4 of 21 sampled patients (Patient 1, 12, 19, and 21) who presented to the emergency department seeking emergency medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.


Patient 1


Review of Patient 1's medical record dated 05/07/24 at 5:00 AM " ...Service(s) being requested: Client came to door asking for help. Client stated he went to crisis as he is suicidal and not safe, client shared that he had overdosed on Saturday and friends used Narcan and he overdosed on Sunday and friends used CPR [Cardiopulmonary Resuscitation]. Non-emergency ambulance called for clients welfare and will be taken to [Above Named Hospital] for evaluation. Client stated he really needs detox and treatment ...."


Review of Patient 1's "Prehospital Care Report" incident date/time 05/07/24 at 5:31 AM showed "Found ambulatory at scene of mental health facility. Staff stated that he had been released from prison last Friday and has been taking meth (methamphetamine), cocaine, fentanyl, alcohol and weed since then; Patient overdosed on Saturday and Sunday ... patient is very lethargic and stated he would like to commit suicide by a fentanyl overdose ...patient report was given and received by hospital RN ..."


Review of Patient 1's, medical record showed, a 36-year-old who presented to the Emergency Department (ED) on 05/07/24 at 6:11 AM by ambulance. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found). His chief complaint was "Pt [Patient] reports to ed [Emergency Department] with complaints of recent drug use. States he took heroin and fentanyl within the last two hours. Pt [Patient] states he was trying to commit suicide by using drugs ..."


Review of "Columbia Suicide Severity Rating Scale (C-SSRS)" dated 05/07/24 at 6:17 AM, showed, "1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? Yes; 2. In the past month, have you actually had any thoughts of killing yourself? Yes; 3. Have you been thinking about how you might do this? Yes. 4. Have you had these thoughts and had some intention of acting on them? Yes. 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? Yes; 6a. Was this within the past three months? Yes. Risk of Suicide High Risk."


Review of Patient 1's "ED Notes" dated 05/07/24 at 7:25 AM, written by Staff O, License Master Social Worker, LMSW showed " ...Suicide Risk/C-SSRS ...Risk of Suicide: High Risk ...Risk Factor Assessment; Suicidal and Self-Injurious Behavior: Actual suicide attempt; Describe preparatory acts: Overdose; Suicidal Ideation (Most Severe in Past Month): Suicidal intent with specific plan (2 days ago); Activating Events (Recent): Pending incarceration or homelessness; Treatment History: Not receiving treatment; Clinical Status (Recent): Highly impulsive behavior, Substance abuse or dependence ... Does the patient need a safety plan completed before discharge? Yes Pt eloped prior to safety plan completion ...Symptoms; Mood/Pt Behaviors: Irritable; Judgment: Impaired; Compliant with Prescribed Medication Regime?: Not on medication; Psychiatric Treatment History; Current Psychiatrist and/or therapist?: No.."


During an interview on 05/31/24 at 9:13 AM, Staff O, LMSW, stated that, Patients that are able to keep themselves safe receive a safety plan. [Patient 1] had a suicidal attempt couple days prior; he had needles falling out of his socks and kept saying that they were insulin needles. Then he started saying he wanted to leave, calling the doctor names, and subsequently. he left against medical advice. He was denying being currently suicidal at the moment I met with him. Since he was being verbally abusive, he was escorted out by security.


Review of Patient 1's "MDM [Medical Decision Making]" dated 05/07/24 at 7:04 AM, showed that, ...Here after heroin use over the last several days. Patient reports he was kicked out of rehab housing. Attempted to go to [Community Mental Health Center] but they did not have bed for him so went up here. Patient sleepy here but arouses to voice. Remains uncooperative. Additional needles found on patient in his pockets and socks. Vital signs otherwise stable. No oxygen requirement. Discussion of potential discharge led the patient to become agitated, belligerent, yelling, and cursing at staff members. Security involved. Patient demanding his syringes be given back to him. Encouraged drug cessation. Resources were provided. Patient left with security.


During an interview on 05/29/24 at 11:28 AM, Staff H, MD (Doctor of Medicine), stated, " ...Looks like he was on, or using drugs the last couple of days and either he left or was dismissed ..." Staff H, MD, shown charting that Patient 1 was high risk for suicide and trying to commit suicide with drugs stated, "it's tricky."


Review of Patient 1's "ED Notes" dated 05/07/24 at 8:50 AM, showed, "Pt becomes verbally aggressive/abusive to staff when being woke up. Pt states he will leave. Security notified and pt escorted to door ..."


Review of "Discharge Instructions - Encounter Notes" on 05/07/24 at 8:52 AM, showed, "Avoid further drug use, follow up on resources provided."


Even though security staff escorted Patient 1 out of the ED, review of an entry titled, "ED Disposition," dated 05/07/24 at 8:57 AM, showed, "Eloped".


Review of Patient 1's medical record on 05/31/24 at 9:28 AM, Staff A, RN, Director of the Emergency Department, stated that Patient 1's disposition was incorrect and it should not be elopement since patient left with security.


Review of Patient 1's medical record failed to show that the hospital provided stabilizing treatment to Patient 1 within reasonable clinical confidence that his medical condition was resolved or that he was no longer considered to be a threat to himself or others, or he had a safety plan or written instruction of resources available to him.


Review of Patient 1's [Community Behavioral Health Center] medical record dated 05/07/24 at 10:21 AM showed " ...Client is struggling with depression and wanting to die/kill himself ..." One hour and 24 minutes after being discharged out of ED from [Above Named Hospital].


Patient 1 returned to the ED on 05/14/24 at 12:22 AM with chief complaint of cellulitis (infection) to lower extremity (leg) with history of injecting fentanyl to this area and discharged at 1:03 AM with a prescription for an antibiotic on the same date. Although Patient 1 denied suicidal ideation during this visit on 05/14/24, review of Patient 1's [Community Behavioral Health Cente [1] medical record on 05/14/24 at 6:15 AM " ...4:13 AM ...client facedown passed out in shower with water running, face in 4-5 inches of water ...the client was pronounced dead @ 4:44 AM ..." Patient was pronounced dead 3 hours and 41 minutes after discharged from emergency room.


Patient 12


Review of Patient 12's medical record showed, a 48-year-old male, presented to the Emergency Department (ED) on 05/17/24 at 1:02 PM by police transportation. Patient 12 was triaged at 1:49 PM with an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found.) His chief complaint was suicidal and homicidal ideation.


Review of Patient 12's "ED Triage Notes" dated 05/17/24 at 1:41 PM, written by Staff G, Registered Nurse (RN) showed, "Pt [sic] arrived with [Police Department] officer who reports that pt [sic] had called and was stating he was suicidal. Pt [sic] has abrasion to left wrist that was self-inflicted. Pt [sic] is here mumbling, and then in raised voice talking about killing someone; someone "on internet." Pt initially pacing around the waiting room. Now sitting and calm. P/w/d [pink/warm/dry]. Eupneic [normal respirations], GCS 14 [Glasgow Coma Scale indicating mild dysfunction. A normal GCS score, indicating full neurological health, is 15]."


Review of Patient 12's "ED Triage Notes" dated 05/17/24 at 1:50 PM, written by Staff G, RN showed, "Pt [sic] wants to kill wants to kill someone named [name] who we [sic] met on the internet because he disrespected him. Pt [sic] oriented x 4. Pt [sic] seems to be preoccupied with Trump winning the election and Microsoft stock winning. Pt [sic] intoxicated, reports drinking 1/2 pint today. Pt [sic] newly homeless after getting into a fight with his neighbor."


Review of Patient 12's "Columbia Suicide Severity Rating Scale (is a suicidal ideation and behavior rating scale)" dated 05/17/24 at 1:52 PM, showed, "...Risk of Suicide High Risk ..."


Review of Patient 12's "ED Notes" dated 05/17/24 at 2:36 PM, written by Staff EE, RN showed, "This RN attempts to locate patient in ED waiting room, as ED room is ready for patient. Upon looking for patient in ED waiting areas, unable to locate. Registrar reports patient left the ED. [Police Department] contacted at 1435 [2:35 PM] for welfare check, sent to voicemail, message left to return call to [phone number] in concern to welfare check needed. [Police Department] returns call at 1540 [3:40 PM], reports they will attempt to contact patient for welfare check."


Patient 12 presented with a complaint of suicidal/homicidal ideation and was at risk for self harm/harm to others. He needed placement in a safe and monitored environment. He was in need of a medical screening examination (MSE) to determine whether he had any other medical conditions contributing to his current psychiatric symptoms/condition. It appeared that he needed a psychiatric evaluation and possible inpatient admission. Instead, Patient 12 left the ED waiting room and did not receive any medical interventions.


During an interview on 05/29/24 at 11:44 AM, Staff G, RN stated that she works triage a lot and it is not uncommon to have a 45-to-50-minute wait before a patient is triaged. Staff G went on to state that if a patient comes in and they're suicidal or homicidal or both and cannot be placed in a room they are put in the front lobby. Staff G stated, "I did not feel the patient met the criteria for room 13 [suicide precautions room] ...The Police Department to my knowledge does not follow up so we do not know if they actually done the welfare check ..."


During an interview on 05/29/24 at 11:27 AM, Staff H, Doctor of Medicine (MD) stated, " ...we will not hold a patient at this facility, we were told by the attorney general we cannot hold the patient regardless if they are suicidal or homicidal ..."


During an interview on 05/30/24 at 3:13 PM, Staff AA, RN stated that we don't notify security if we place a patient in the waiting room that is suicidal or homicidal due to confidentiality.


Patient 19


Review of Patient 19's medical record showed, a 22-year-old, presented to the ED on 10/29/23 at 1:56 PM by private vehicle with mother, and two other family members. Patient 19 was triaged at an ESI 2.


Review of Patient 19's "ED Triage Notes" showed, "Pt [Patient] to triage accompanied by mother seeking inpatient tx [treatment] for pt [sic] who is manic (showing wild, apparently deranged, excitement and energy). Per mother, pt [sic] took LSD (Lysergic acid diethylamide a potent hallucinogen drug that alters person perception of reality) previous Tuesday and has had suicidal tendencies since that time. Pt [sic] refused to let RN [registered nurse] place ID [identification] bracelet at this time as she states, " I died last Tuesday". Pt [sic] not answering additional questions at this time."


Review of Patient 19's "ED Triage Notes" dated 10/29/23 at 2:02 PM, showed, "Pt [sic] delayed in answering questions in triage. Pt [sic] states she knows where she is and "her worst fears have come true."


Review of Patient 19's "Columbia Suicide Severity Rating Scale" dated 10/29/23 at 2:06 PM, "...Risk of Suicide High Risk ..."


Review of Patient 19's "ED Provider Notes" dated 10/29/23 at 2:23 PM, showed, "Chief Complaint; Patient presents with Altered Mental Status ...Physical Exam ... Neurological: Mental Status: She is alert. ...Psychiatric: Comments: Patient agitated ... Medical Decision Making: 21-year-old female here today with parent and concern for manic behavior. Patient has a history of bipolar apparently. Parent also relating that patient took LSD several days ago. Patient speaking loudly in an agitated manner. She is approaching hitting room occupants including other patients and their family members. She occasionally is shouting and raising her voice. She does not appear to be physically aggressive. No evidence of trauma. She is speaking clearly without difficulty. Her movement is purposeful. Does not appear to be any focal or unilateral neurological deficits. Patient does not appear to be short of breath. She has good muscle tone. Patient was offered multiple times to be taken to a room for evaluation and treatment. Patient not responding to questions. After a brief moment of being somewhat calm she began to get agitated again. Again she declined to answer or respond to multiple offers of being roomed, evaluated, and treated. Given the lack of cooperation, patient was then discharged. She was escorted from the waiting room by security. Parent is with patient. Nothing in patient interaction indicating that patient does not have capacity to make her own decisions. Discussed at length with parent that we could not force patient to be evaluated ..."


During an interview on 05/29/24 at 2:01 PM, Staff P, Advanced Practice Registered Nurse (APRN), stated, " ...We don't do MSE's in the waiting room but if a patient is being uncooperative or not answering questions, it's difficult to see if they are alert and orientated. If unable to get history from patient, we would try to get history from family. Safety would be our number one concern. My guidelines are that we are not to physically force any patient into a room per the hospital policy. The attorney general came and told us that we can't force people to be treated against their will. The social worker does the heavy lifting on the patients to see if they need to be admitted..."


Review of "Discharge Instructions - Encounter Notes" dated 10/29/23 at 2:33 PM, showed, "Follow up with your doctor in two days. Return to the emergency room as needed."


Review of "ED Notes" dated 10/29/23 at 2:35 PM, showed, "Pt [Patient] escorted out with the assistance of security. Unable to provide discharge instructions."


Review of "ED Notes" dated 10/29/23 at 2:45 PM, written by Staff Y, LMSW (Licensed Master Social Worker) showed, "Patient brought to ED by her mother. ED SW [Social Worker] contacted by triage nurse that patient was agitated and screaming in the ED lobby. ED SW went to lobby and patient had been taken to the parking lot by security due to her disruptive behavior in the lobby. ED SW went to the parking where patient was with her mother and two friends. Also present was security officers and charge nurse. Patient was making statements such as, "I have been saved." And "God is with me." Patient's mother had paperwork stating she is patient's legal guardian. ED provider had seen patient earlier and patient refused to be roomed for assessment. Patient was discharged and told if she returned, [Local Police Department] would be called for criminal trespass by security. Recommendation was for patient to go to [Community Behavioral Health Care 1]. Patient left with her mother and two friends. ED social worker left a message on the [Community Behavioral Health Care 1] Crisis Intake message line of patient being brought by her mother."


Review of document titled "IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION 12" electronically filled 2022, Dec, 08 AM 11:46, showed, "LETTERS OF GUARDIANSHIP; [Patient 19's Mother], having been appointed and qualified of [Patient 19], an adult with an impairment in need of a guardian, is granted Letter of Guardianship with full power and authority as provided by law, including all powers and duties of a guardian set out in K.S.A. 59-3075 and 59-3077. IT IS SO ORDERED ...Honorable [Judge 1], District Judge ..."


During an interview on 05/30/24 at 12:30 PM, Staff Y, LMSW, stated, "...The patient was psychotic she had not been taking medication screaming, "I'm god" and "I have been saved" they were instructed to come to ED for involuntary hold by EMS. [Hospital 1] would not put a hold on her, she was out in the parking lot because of her disruptive behavior and was told she could not come back because of disruptive behavior. The mother had paperwork in her hand, but I did not look at paperwork she was holding. I don't know why she wasn't let back in; we do let other patients that are disruptive stay all the time..."


Review of hospital document titled "Patient Relations" dated 01/02/24 at 10:53 AM, showed, " ...Patient name: [Patient 19] ...Admission Date: Oct 29, 2023, 1:56 PM ...Narrative description: Patient mother has submitted survey feedback regarding daughter care that she received [sic] from her visit in the ER on 10/29/2023: ...I am [Patient 19's mother] the mother and guardian for [Patient 19]. I know my daughter's condition Bipolar I Manic is complicated. I showed up in the ER told the front desk people that ...I have guardianship paperwork ... Once she was in your ER ... the doctor came in the waiting room and said no he wouldn't help her. She was pushed out of the door by 3 security officers, and 2 to 3 nurse staff. Then they shoved her in my car and didn't give us any direction on what we should do ... "Doctor didn't even ask me about her condition just that he would not treat her ..."


During an interview on 05/30/24 at 2:51 PM, Patient 19's mother (F1) stated that the hospital kicked us out before Patient 19 was seen for being manic and trying to hurt herself. She stated that she had guardianship paperwork and asked if there was a room to put her in because while the nurses were questioning, he she stared to grab at staff and all the hospital things. She stated that the staff said no and told her that she would need to wait in the waiting room. F1 stated that she told staff that it was not going to be good to have her in the waiting room ... F1 stated that Patient 19 started screaming at the top of her lungs and messing with other people not 2 seconds later. She stated the doctor came in and said that they could not treat her, and they need to go to the Community Behavioral Health Care 1. F1 stated that they were thrown out and it took six people to pick her up and throw her out of the hospital. She stated that the hospital told her is she came back it would be trespassing. F1 stated that a lady cop said that she was trying to be nice, but that Patient 19 just couldn't come there anymore. F1 stated that she then drove to a hospital in Kansas City on 10/29/24, and Patient 19 was admitted.

Patient 19 came into the ED demonstrating psychiatric symptoms and behaviors. She needed placement in the ED in a safe and monitored environment. Patient 19 needed a psychiatric evaluation and, if necessary, inpatient psychiatric admission/treatment. Patient 19 needed an MSE to determine if she had any other current medical conditions contributing to her psychiatric symptoms/condition. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 19.


During an interview on 05/30/24 at 3:44 PM, Staff T, Security Guard stated "I was approached by her mother, she had exhausted all of her resources and was looking for help. The patient was very agitated and mother stated she would respond to gentle talking. The doctor asked in waiting room if she wanted help and would not respond to doctor. The patient would yell and verbally attack her mother. She was asked to leave and wouldn't leave, then she threw herself on the ground, so I put her in a body wrap to keep harming herself. I told her that she still needed to get help after I put her in the car."


During an interview on 05/30/24 at 12:09 PM, Staff U, Armed Security, stated that Patient 19 was having a mental health crisis. Her mom had wanted her to stay and be treated. The patient was talking loudly and having abnormal conversations with other waiting room patients and throwing herself on the ground. Staff U spoke to the mother about patient options which is jail with law enforcement or hospitals. Staff U went on to state that for mental health patients they will be asked to leave, be arrested and released. Then return to the hospital to get help and get trespassed again so it's a circle, due to a lack funding and we tend to pass them around."


During an interview on 05/31/24 at 9:28 AM Staff A, RN Director of Emergency Department, stated that, if a patient states that they want to harm self or others, the doctor would decide if the patient had capacity if they did not have capacity. Then doctor would do ex parte order to hold the patient. If provided with guardianship paperwork we would copy paperwork and put into the chart ..."


Review of medical record failed to show that patient received emergency medical examination for a medical condition manifesting itself by acute psychiatric disturbances and/or symptoms of substance abuse, or no longer considered to be a threat to himself/herself or others. Further review of the medical record failed to show F1 was allowed to make medical decisions for Patient 19 as her legal guardian.


Review of Patient 19's Hospital 3 medical recorded dated 10/29/23 at 3:31 PM, 56 minutes after being dismissed from Hospital 1, showed Patient 19 presented to ED with bipolar mood disorder type 1 (Period of abnormally elevated or irritable mood and high energy, accompanied by abnormal behavior that disrupts life) with psychotic symptoms (experiencing delusions, hallucinations or confused and disturbed thoughts).


Patient 21


Review of a document titled, "EMS Patient Care Report" showed, Patient 21, a 45-year-old male with Altered Level of Consciousness and Chest Pain Suspected Cardiac on 05/15/24 at 5:35 PM.


Review of a document titled, "EMS Patient Care Report" showed, "[Ambulance Service] dispatched for a sick at a skilled nursing facility non-emergent. [Ambulance Service] went enroute as [Ambulance Service] was passing by sidewalk in front of [Hospital 1] ambulance bay as a small group of bystanders and law enforcement officers were frantically waving [Ambulance Service] down to stop as there was an unconscious male lying on the side walk. [Ambulance Service] pulled over and diverted to that call. Bystanders reported that they found the patient like this, unknown when or how he fell. Patient had emesis noted on the ground next to his mouth. Airway patient and breathing adequately. Patient woke to painful stimulation. Patient reported that he had chest pain and was attempting to get to [Hospital 1]. Patient also reported that he has a history of seizures. [Ambulance Service] and fire crew assisted patient onto cot via sheet lift and secured with all seatbelts. Secured in ambulance. Vital signs on scene were stable. IV attempt made on scene. Patient denied any injuries or pain other than pain in his chest. Patient refused aspirin as he felt like he could not take it. [Ambulance Service] went enroute to hospital. Patient became more alert enroute but remained confused. Vital signs remained stable with no further changes in assessment findings. Diverted from [Hospital 1] to [Hospital 2] ..."


Review of a document titled, "Incident Report" dated 05/15/24 at 5:30 PM showed, " ...At around 1730 [5:30 PM] hours on the above date, [Staff CC, Security] was dispatched to the area of 10th and Washburn on a man down. As [Staff CC] was entering the area, [Staff CC] was advised that the subject was on the sidewalk near the southren [sic] lower helipad. On scene, there were two unkknown [sic] employees and a bystander trying to assist. [Staff CC] noted that male subject was on his left side, vomiting. One of the unknown employees was a medical staff member. Sternum rubs were given with little response from the subject. [Staff CC] began to search the subject and found two long knives and a expandable baton [sic]. [The Ambulance Service] was dispatched. A [Police Department] officer arrived and assisted with trying to obtain the subjects name. The medical staff employee found an alert bracelet that stated that he had heart issues. [Ambulance Service] arrive, along with [Fire Department] and they took over care of the patient. [Staff CC] alerted the ER officers that this subject was on the way there and that he had weapons on his person. The weapons were placed in the subjects backpack. [Staff CC] cleared at this time ..."


During an interview on 05/29/24 at 5:17 PM, Staff V, Paramedic, stated, "this is a very odd case because the patient was on the sidewalk closest to [Hospital 1] ...the patient was right there by the fence of the helicopter pad ...[The Ambulance Service] happened to be driving by and see everyone flagging [The Ambulance Service] down ...when [The Ambulance Service] arrived [Hospital 1] security and a woman in scrubs were attending to [Patient 21] ...called to give a radio report to [Hospital 1] but [Hospital 1] said divert we told [Hospital 1] [Patient 21] was trying to get into their Emergency Department and [Hospital 1] stated again please divert ..."


During an interview on 05/30/24 at 4:31 PM, Staff CC, Security, stated that there was a man down on the sidewalk by the lower helicopter pad with vomit on the ground laying on his left side and [Hospital 1] dispatch called [The Ambulance Service]. Staff CC went on to state, "...I heard on the radio that [The Ambulance Service] got rerouted to [Hospital 2] even though they were literally right there at the ambulance bay ..."


During an interview on 05/31/24 at 9:28 AM, Staff A, RN Director of Emergency Department, stated, " ...if you are on our property and need medical attention, we would see you regardless if on diversion ..."


Patient 21 was found down next to the ambulance bay with decreased responsiveness and later complaining of chest pain. Patient 21 did not receive an MSE from the hospital. The hospital failed to do a history and physical, an EKG, any labs, or any imaging studies to determine whether the patient had an EMC. Since Patient 19 did not recieve an appropriate MSE, they could not determine whether the patient needed any cardiac stabilizing treatments like aspirin, cardiac consultation, cardiac catheterization, and/or hospitalization. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 21 and so he was taken to Hospital 2 by ambulance.