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Based on interview, record review, video review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening exam (MSE) for one patient (#6). The hospital also failed to maintain an accurate central log for patients presenting to the emergency department (ED) for care. They failed to accurately document the disposition of six patients (#6, #7, #9, #15, #17, #24, and #25) and to maintain an ED log for the period of 04/07/22 through 06/15/22, in regards to six patients (#20, #26, #27, #28, #29, and #30) selected, of 31 ED records reviewed from February 2022 through August 2022. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's combined average monthly ED census over the past six months was 5,529.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an EMC) Definitions and General Requirements," dated 09/01/19, showed that a MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists; screening is to be conducted to the extent necessary, by physicians and/or other qualified medical profession (QMP) to determine whether an EMC exists; and with respect to an individual with behavioral symptoms, a MSE consists of both a medical and behavioral health screening.

Although requested, a policy regarding the maintenance and required documentation of a Central ED Log was not provided.

Although requested, the hospital was unable to produce a Central ED Log for the dates of 04/07/22 through 06/15/22. The hospital provided an unlabeled report, pulled from financial data, with minimal patient information for that time frame. All patients were listed by account numbers only, and all dispositions for this time frame were documented as home. The patient selection pulled from the unlabeled report consisted of a total of six patients (#20, #26, #27, #28, #29, and #30).

Review of Patient #6's medical record showed that she presented to the ED on 08/09/22 at 1:02 PM with a stated complaint of suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideantion (HI, thoughts or attempts to cause another's death) and off her medications. Triage (process of determining a priority of a patient's treatment based on the severity of their condition) note showed the patient was escorted out by KCPD and medications were not given. Medication orders were documented for Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder) and Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure). There was no MSE documented. Patient #6 was discharged at 1:16 PM.

Please refer to 2405 and 2406 for further details.

Based on interview, record review and policy review the hospital failed to maintain an accurate central log for patients presenting to the emergency department (ED) for care. They failed to accurately document the disposition of six patients (#6, #7, #9, #15, #17, #24, and #25) and to maintain an ED log for the period of 04/07/22 through 06/15/22, in regards to six patients (#20, #26, #27, #28, #29, and #30) selected, of 31 ED records reviewed. The hospital's combined average monthly ED census over the past six months was 5,529.

Findings included:

Review of hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an emergency medical condition) Definitions and General Requirements," dated 09/01/19, showed that all individuals that arrive at the ED seeking emergency treatment should be placed on a Central ED Log. The purpose of the log would be to track whether the individual refused treatment, was refused treatment, whether they were admitted and treated, stabilized and transferred, or discharged.

Although requested, a policy regarding the maintenance and required documentation of a Central ED Log was not provided.

During an interview on 08/16/22 at 10:45 AM, Staff D, Chief Nursing Officer (CNO), stated that they were unaware that there were missing portions of the Central ED Logs until requested by the survey team. They identified that April, May, and half of June were missing. The ED Director was out on maternity leave and there had not been an interim ED Director put in place until June 2022.

Review of the ED log dated 08/09/22 showed that Patient #6 presented to the ED on 08/09/22 at 1:02 PM with no disposition listed.

Review of Patient #6's medical record showed that she presented to the ED on 08/09/22 at 1:02 PM with a chief complaint of suicidal ideation (SI, thoughts of causing one's own death), homicidal ideations (HI, thoughts or attempts at causing another's death) and off her medications. She was discharged to home.

Review of the ED log dated 08/09/22 showed that Patient #7 presented to the ED on 08/09/22 at 2:16 PM with no disposition listed.

Review of Patient #7's medical record showed that she presented to the ED on 08/09/22 at 2:16 PM with blockages in her legs and left without being seen (LWBS) after triage (process of determining the priority of a patient's treatment based on the severity of their condition).

Review of the ED log dated 08/06/22 showed that Patient #9 presented to the ED on 08/06/22 at 5:06 PM with no disposition listed.

Review of Patient #9's medical record showed that she presented to the ED on 08/06/22 at 5:06 PM with ingestion of methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) and LWBS after triage.

Review of the ED log dated 07/16/22 showed that Patient #15 presented to the ED on 07/16/22 at 6:56 PM with no disposition listed.

Review of Patient #15's medical record showed that she presented to the ED on 07/16/22 at 6:56 PM with SI, HI, and assault. She left prior to receiving a medical screening exam (LPMSE).

Review of the ED log dated 06/27/22 showed that Patient #17 presented to the ED on 06/27/22 at 3:51 PM with no disposition listed.

Review of Patient #17's medical record showed that she presented to the ED on 06/27/22 at 3:51 PM with a complaint of inability to stay awake. She was discharged to home at 6:44 PM.

Review of the ED log dated 03/06/22 showed that Patient #24 presented to the ED on 03/06/22 at 11:20 AM with no disposition listed.

Review of Patient #24's medical record showed that she presented to the ED on 03/06/22 at 11:20 AM with burns to her hands. She had been place on the ED log under a different name. The medical record documentation was under another name, her correct name. She was discharged to home.

Review of the ED log dated 03/18/22 showed that Patient #25 presented to the ED on 03/18/22 at 5:56 AM with no disposition listed.

Review of Patient #25's medical record showed that he presented to the ED on 03/18/22 at 5:56 AM with muscle aches, but LPMSE.

Although requested, the hospital was unable to produce a Central ED Log for the dates of 04/07/22 through 06/15/22. The hospital provided an unlabeled report, pulled from financial data, with minimal patient information for that time frame. All patients were listed by account numbers only, and all dispositions for this time frame were documented as home. The patient selection pulled from the unlabeled report consisted of a total of six patients (#20, #26, #27, #28, #29, and #30).

Review of the hospital's untitled report dated 04/30/22 showed that Patient #20 presented to the ED on 04/30/22 at 9:17 PM with home listed under disposition.

Review of Patient #20's medical record showed that he presented to the ED on 04/30/22 at 9:17 PM with SI and agitation (a state of feeling irritated or restless). He was discharged to home.

Review of the hospital's untitled report dated 05/02/22 showed that Patient #26 presented to the ED on 05/02/22 at 10:38 PM with home listed under disposition.

Review of Patient #26's medical record showed that he presented to the ED on 05/02/22 at 10:38 PM with an opiate overdose. He was discharged to home.

Review of the hospital's untitled report dated 04/07/22 showed that Patient #27 presented to the ED on 04/07/22 at 8:34 PM with home listed under disposition.

Review of Patient #27's medical record showed that she presented to the ED on 04/07/22 at 8:34 PM with a request for medication refill and food. She was discharged to home.

Review of the hospital's untitled report dated 04/12/22 showed that Patient #28 presented to the ED on 04/12/22 at 6:08 PM with disposition to home.

Review of Patient #28's medical record showed that he presented to the ED on 04/12/22 at 6:08 PM with SI. He was admitted to the psychiatric center.

Review of the hospital's untitled report dated 05/26/22 showed that Patient #29 presented to the ED on 05/26/22 at 4:23 PM, no diagnosis listed, with disposition to home.

Review of Patient #29's medical record showed that he presented to the ED on 05/26/22 at 4:23 PM with an intentional overdose, over the counter cold medication, five boxes with 16 tablets each, a total of 80 tablets. He was held in the ED pending psychiatric placement and ultimately discharged to home on 05/28/22 at 5:30 PM.

Review of the hospital's untitled report dated 05/31/22 showed that Patient #30 presented to the ED on 05/31/22 at 7:17 AM, no diagnosis listed, with disposition to home.

Review of Patient #30's medical record showed that he presented to the ED on 05/31/22 at 7:17 AM with SI. He was transferred to an inpatient psychiatric hospital.









39840

Based on interview, record review, policy review and video review, the hospital failed to provide within its capability and capacity, an appropriate medical screening exam (MSE) for one patient (#6) out of 31 Emergency Department (ED) records reviewed from February 2022 through August 2022. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's average monthly ED census over the past six months was 5529.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an EMC) Definitions and General Requirements," dated 09/01/19, showed that a MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists; screening is to be conducted to the extent necessary, by physicians and/or other qualified medical profession (QMP) to determine whether an EMC exists; and with respect to an individual with behavioral symptoms, a MSE consists of both a medical and behavioral health screening.

Review of Kansas City Police Department's (KCPD) document titled, "Mental Health /Crisis Intervention Team (CIT) Report," dated 08/09/22, showed that Staff T, Police Officer (PO), was called to Patient #6's home where he found a neighbor that reported the patient was threatening to harm others, was a danger to herself, had an edged weapon, was using alcohol, had a mental health diagnosis of bipolar (characterized by clear changes in mood, energy, and activity levels with periods of extremely energized behavior) and schizophrenia (a serious mental disorder that affects a person's ability to think, feel, and behave clearly). The report showed that the patient was on medications but was noncompliant and was currently in services with an outpatient mental health clinic.

Review of KCPD's document titled, "Narrative," dated 08/09/22, showed that Staff T, PO, first responded to Patient #6's home address where it was reported by a neighbor that the patient was making statements that she believed some neighbors were going to shoot her and another neighbor; people were trying to kill her. She began threatening people with a hatchet like object. The patient was not found at the first location. Staff T responded to a second location after he saw a woman that fit the description of the patient and where Staff S, PO, responded on a separate call. It was a liquor store where the patient was found drinking alcohol inside and had not paid. No charges were being brought against the patient. Patient #6 was released to Staff T who called Emergency Medical Services (EMS, ambulance), to transport the patient to the hospital for a mental health evaluation. The patient stated to Staff T, that she was followed and threatened by neighbors who she could not identify. The patient stated she heard the neighbors who talked about shooting her and a neighbor. The patient stated she, "might have to kill them before they kill her." Once the patient arrived to the ED, the patient began to panic stating she did not want to go to the "alien room." She stated she was scared of the aliens and then tried to hide in a corner. The patient was crying and appeared terrified. A female provider asked why Patient #6 was there. Staff T explained the circumstances that led to the mental health evaluation. The provider responded, "I'm the provider, I'm clearing her medically, just take her to jail." He advised her that there were no charges being brought against her and it was purely a mental health service. The provider responded, "I'm medically clearing her, just get her out of my hospital." The patient was discharged from the hospital at that time without being seen or treated.

Review of the Kansas City Fire Department (KCFD) EMS document titled, "Patient Care Record, Incident #: 22-105470," dated 08/09/22, showed that Patient #6 was a 27 year old woman that had a Primary Impression of "Behavioral/psychiatric episode," Chief Complaint was, "Needs meds." Signs and Symptoms were, "Behavior/Emotional State, strange and inexplicable behavior," Mental Status, "Event oriented, hallucinations, person oriented, place oriented, time oriented." Patient stated she was off her medications and wanted to get back on them. The patient displayed strange behavior and hallucinations. The patient denied suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideations (HI, thoughts or attempts at causing another's death). The patient was transported to the hospital with Staff S, PO, who sat in the back with the patient. Patient #6 was transported without incident. Report was given and patient care was transferred to the Registered Nurse (RN) at the receiving hospital.

Review of KCPD's Body Cam Video, "tkj00771_20220809171707e0_20220809172705_01_001w.mp4," verified by KCPD as dated 08/09/22, showed that the first response by police was at the patient's home address. Patient #6's neighbor stated the patient had a weapon that was "like some sort of pick ax or something, screaming and shit." The neighbor reported that earlier the patient had thrown her clothes and things out of her house, as she pointed to the front yard. The neighbor reported that the patient was picked up by an ambulance earlier that day and she returned at about 11:30 AM that morning. The patient was first calm and then began talking about how she wanted to die and wanted to kill herself. As the patient sat and waited for an ambulance the neighbor had called, she became more paranoid (excessive suspiciousness without adequate cause); she picked up the next door neighbor's weed eater and stated she needed a weapon. The patient insisted someone was there to kill her neighbor, although no one was around. The patient reportedly had put her shoes on and ran up the street. The officer was unable to locate the patient.

Review of KCPD's Body Cam Video, "tjk00771_20220809173706e0_20220809173636_01_000w.mp4," verified by KCPD as dated 08/09/22, showed that the second response by police was to a liquor store where the patient was found drinking alcohol and had not paid for it. The patient was sitting on a curb, handcuffed and was giving the officer identifying information. The liquor store decided to not press charges against the patient. The patient verified her address where the police had first responded. The patient stated to the police officer, "I don't want my neighbor to die." She requested the police go check on her neighbor's safety. She stated, "I just want to protect my neighbor from somebody shooting her." She reported that two neighbors were going to shoot her and her neighbor. She stated she felt like her neighbors were watching her. The patient admitted to hearing voices and stated she was schizophrenic and bipolar. The patient stated she was off her medications for a couple days and felt like things had gotten worse. The patient stated she wanted to get back on her medications. The police officer stated he had called an ambulance and the patient agreed to go to the hospital for help. The officer was heard stating he had enough information for a Crisis Intervention Team (CIT) report. The patient remained calm and appeared drowsy sitting on the curb. The patient had the handcuffs removed and began to walk off. The police were able to redirect the patient into the ambulance. A police officer got into the back of the ambulance and accompanied the patient to the hospital for safety of the EMS staff.

Review of the hospital's ED video, verified by the hospital as dated 08/09/22, showed that Patient #6 walked into the ED and was escorted by KCPD and EMS. The paramedic and EMT left the ED. Within minutes, the patient was seen leaving the ED and was escorted by hospital security and KCPD. Once the patient was outside, she was seen walking across the parking lot alone until out of the camera's view.

Review of Patient #6's medical record showed that she presented to the ED on 08/09/22 at 1:02 PM with a stated complaint of SI and HI and off her medications. Triage (process of determining a priority of a patient's treatment based on the severity of their condition) note showed the patient was escorted out by KCPD and medications were not given. Medication orders were documented for Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder) and Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure). There was no MSE documented. Patient #6 was discharged at 1:16 PM.

Review of the ED log dated 08/09/22 showed that Patient #6 presented to the ED on 08/09/22 at 1:02 PM with the chief complaint of SI and HI and off her medications. The patient's disposition was logged as home.

Review of the hospital's document titled, "Research Medical Center On Call Schedule," dated 08/09/22, showed that two psychiatrists were on call at the time of Patient #6's ED visit.

During an interview on 08/15/22 at 3:40 PM, Staff F, RN, stated that she had not recalled caring for Patient #6. Medication could have been ordered by the provider and not given if the patient had calmed herself down. If a patient retracted saying they had SI or HI, the patient could have been discharged.

During an interview on 08/15/22 at 4:32 PM, Staff H, Advanced Practice Provider (APP), stated that Patient #6 was well known to the ED for substance abuse and psychosis. The police told her that the patient was found at a liquor store drinking alcohol and acting erratically; the police were called and they picked the patient up and brought her to the ED. Patient #6 refused to go into a psychiatric (relating to mental illness) room; the patient "lost her mind," collapsed to the floor crying out that she would rather have gone to jail than into one of those rooms. EMS told her the police were arresting the patient. Staff N, Security Guard, was there with the patient but had not touched her; the patient was not aggressive. The patient denied SI or HI. The patient was de-escalated and then was assessed. She performed a MSE but had not documented it. The police officers never said anything about a 96-hour hold (court ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) or an affidavit (a written statement confirmed by oath, for use as evidence in court).

During an interview on 08/16/22 at 11:09 AM, Staff I, RN, stated that the APP only talked to the patient, but no physical assessment was performed. Security and two police officers walked the patient out of the ED; the patient was calm and not handcuffed. There were mental health providers on call every day for assessment of patients.

During an interview on 08/16/22 at 12:15, Staff O, ED Charge Nurse (CN), stated that the patient came in calmly and escorted by police. Patient #6 cried that she would rather go to jail than to one of the rooms (referring to the psychiatric rooms). The patient was cleared medically by Staff H, APP. The police officers never mentioned a 96-hour hold or an affidavit needed because she was a notary and would have been the one who signed the paperwork.

During an interview on 08/16/22 at 12:25 PM, Staff N, Security Guard, stated that he saw Patient #6 sitting in a corner crying and said she would rather have gone to jail than to have gone into one of the rooms. Staff H, APP, stated that if the patient had nothing medically wrong, she was cleared to leave the ED. He had to escort them out to unlock the doors.

During an interview on 08/18/22 at 4:50 PM, Staff S, PO, stated the patient did not have a weapon when found at the liquor store. He accompanied the patient in the ambulance to the hospital. Staff T, PO, stated that he was filling out a CIT and affidavit. The patient was calm until she was by the psychiatric rooms where she became emotional and appeared frightened. She stated she would have rather gone to jail than into one of those rooms. Staff H, APP, stated that the patient was medically cleared and was no longer needed there. The patient was allowed to leave the hospital alone because she was not under arrest.

During an interview on 08/19/22 at 12:56 PM, Staff T, PO, stated that he first responded to a mental health call at Patient #6's home address. The patient was not there but he had spoken to the neighbor that made the 911 call. The neighbor reported that the patient had a hatchet like weapon and thought other neighbors were going to shoot them; the patient became increasingly paranoid. He never saw a weapon at the scene. The neighbor thought the patient was seen earlier at the hospital. He responded to a second location, a liquor store, where the patient was found drinking alcohol and had not paid. The liquor store had not charged the patient, therefore Staff S, PO, released the patient to him and she was then taken to the hospital for a mental health examination. The patient was calm and cooperative. The patient stated that she would kill the others before they could kill her. Upon arrival to the hospital, the patient cried and appeared scared of the psychiatric rooms. She stated she would have rather gone to jail than go into one of those rooms. The provider yelled back and forth with the patient; there was a lot of commotion. He told the provider about the 96-hour hold, but she may not have heard him. He was given an affidavit by the hospital staff, but he had no time to fill it out because she was discharged so quickly. Staff H, APP, stated that the patient was medically cleared and to take her out of the hospital; security escorted the patient out of the hospital. The patient was allowed to walk off hospital grounds because she had not been charged with any crime.

During an interview on 08/22/22 at 10:22 AM, Staff U, Paramedic, stated that they were called by police to transport a patient for a behavioral health episode. The patient was picked up at a liquor store. She was the one that took care of the patient in back of the ambulance. The patient was calm and cooperative. Patient #6 told her that she needed to get back on her medications. The patient denied any SI or HI. The patient exhibited strange behavior, talking to the wall of the ambulance and did not make any sense. Upon arrival to the ED, the patient's demeanor changed and she had become more paranoid about going back to the psychiatric rooms. The police stated they planned to do a CIT and an affidavit, which was the purpose of the visit. Report was given to the hospital staff upon arrival. She saw the patient on the street alone after leaving the hospital grounds.

During an interview on 08/22/22 at 10:35 AM, Staff V, Emergency Medical Technician (EMT), stated that she was the driver of the ambulance and did not have much interaction with the patient; the patient exhibited strange behavior like she was anxious and paranoid.

During an interview on 08/15/22at 3:50 PM, Staff G, ED Physician, stated that he did not see Patient #6 when she arrived. He initially signed up to care for the patient, but Staff H, Advanced Practice Provider (APP), saw the patient first. Staff H informed him she assessed Patient #6 and completed a MSE; the patient was cleared medically and was discharged. He expected a MSE to have been documented in the medical record if it was performed. All patients who presented to the ED should have a MSE documented.

During an interview on 08/17/22 at 4:21 PM, Staff R, ED Medical Director, stated that he would have expected a MSE to have been performed and documented on every patient that came through the ED doors. It depended on how the patient presented to the ED if a psychiatric evaluation was performed; this patient was calm.