HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to provide a medical screening examination sufficient to determine a medical emergency for two patients (#1 and #30), and failed to provide stabilizing treatment within its capacity and capability for one patient (#29) out of a sample selected from March through August, 2013. The Emergency Department (ED) sees an average of 2953 patients per month.

Findings included:

1. Review of hospital policy, "Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA)" dated 08/10, showed that an emergency medical condition manifests 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 placing the health of the individual in serious jeopardy. The policy further states that with respect to a psychiatric patient, that there is a substantial risk of the individual harming himself or others ...or that substantial impairment or obvious deterioration of the individual's judgment, reasoning, or behavior may result in the individuals' inability to function independently as appropriate for age. Further review of the hospital policy showed that a psychiatric emergency medical condition meant a condition that exists when an individual presents an immediate threat to himself or others ...and includes severe depression, acute psychosis, dissociative state, inability to comprehend danger or to care for one's self.

2. Review of Patient #1's medical record from St Luke's Hospital (St Luke's Hospital of Kansas City) , showed that when the patient was taken to the ED on 07/30/13 at 9:35 PM, he was combative, uncooperative, verbally inappropriate, unpredictable, and agitated with aggressive behavior. The patient was restrained, but freed himself from the restraints and attempted to elope stating "he did not want to be here". Physician's documentation showed that the patient was intoxicated, anxious, hostile and frustrated, and required security at the patient's bedside. The patient attempted to elope again and was escorted out of the ED by hospital security, prior to a psychiatric examinations by a mental health professional and without toxicology screening of the patient's blood or urine.

3. Record review of the hospital's on-call list showed that a Social Worker and Psychiatrist (perform psychiatric examinations) were on-call while Patient #1 was in the ED.

4. Review of law enforcement reports dated 07/30/13 and 07/31/13, showed that on 07/30/13, after Patient #1 was escorted out of St Luke's Hospital, he was observed driving a vehicle that struck another vehicle, struck a stop sign, and then drove off. Further review of the reports alleged that the patient abandoned the first vehicle (stolen by Patient #1), car-jacked a second vehicle, and crashed the second vehicle into a utility pole, causing Patient #1 significant injury which required hospitalization.

5. Review of Patient #1's ambulance report dated 07/30/13 showed that 20 minutes after the patient was released from St Luke's Hospital, he wrecked a car traveling at a high rate of speed, had a strong odor of alcohol on his breath, and was found on the ground next to the driver's side of a vehicle that had struck a light pole and broke the pole in half. Patient #1 complained of right hip pain and was transported emergently by ambulance to Hospital B.

6. Review of Patient #30's medical record showed that he presented to the ED by ambulance on 07/14/13 at 7:27 PM with alcoholism. This was the patient's fourth visit to the ED in 24 hours for uncontrolled substance abuse and intoxication. An application for a 96 hour hold was completed by a physician and social worker because he presented a "likelihood of serious harm to himself". While the 96 hour hold application was being processed, the physician wrote the patient's discharge orders without obtaining a psychiatric examination by a mental health professional and without obtaining a toxicology screening of the patients blood or urine, and left her shift. The patient was not appropriately monitored, and at 3:07 AM, while the 96 hour hold application was still in process, the patient eloped from the ED and could not be found.

7. Record review of the hospital's on-call list showed that a Social Worker and Psychiatrist were on-call for the hospital while Patient #30 was in the ED.


8. Review of the hospital policy, "Referral for Voluntary/Involuntary Commitment (96 Hour Hold)" dated 07/09, showed that a referral for Civil Involuntary Detention Process will be instituted for the detention of a patient for mental health treatment when the person exhibits behavior that indicates a mental disorder, illness or substance abuse problem. Further review showed that after it is determined that the likelihood of harm is present, the patient will be placed on one-to-one observation.


9. During a telephone interview on 08/15/13 at 5:49 PM, Social Worker W stated that she completed a 96 hour hold application for Patient #30 because she thought the patient might die. Social Worker W stated that the patient was "extremely intoxicated" and his judgment and safety were impaired because of his continued drinking and exposure to extreme heat.


During an interview on 08/19/13 at 4:46 PM, Nurse V stated that patients who were "drunk or violent" weren't monitored closely, and because of this, Patient #30 was able to elope front he ED.



10. Record review of an ambulance report dated 07/15/13 showed that EMS responded to Patient #30 at 8:52 AM, after the patient was found unresponsive with an empty bottle of vodka. The patient remained unresponsive after ambulance staff physically shook him and shouted at him, so the patient was transported to St. Luke's Hospital ED.

11. Record review of a medical record dated 07/15/13 showed that Patient #30 arrived to the ED at 9:17 AM. The patient appeared intoxicated and sleepy, his speech was slurred, he was lethargic (slow to move or respond), did not show functional capacity, and had reported to ambulance staff that he drank 750 milliliters of alcohol that morning. There was no evidence that the patient received a psychiatric examination or a toxicology screening of his blood or urine, and because the patient was not appropriately monitored, he eloped from the ED without the knowledge of staff.

12. Record review of the hospital's on-call list showed that a Social Worker and Psychiatrist were on-call for the hospital while Patient #30 was in the ED.

13. Record review of an ambulance report dated 07/17/13, showed that EMS responded to Patient #30 at 12:22 PM, after local law enforcement found the patient on the sidewalk, complaining of abdominal pain and bleeding, and exposing his genitals several times. The patient, who was not alert, was transported to the St. Luke's Hospital ED.

14. Record review of a medical record dated 07/17/13, showed that Patient #30 arrived to the ED at 1:09 PM, after the patient was "found intoxicated" by local law enforcement. This was the patient's fourth visit to the ED over the last three days for alcohol related issues. There was no evidence that the patient received a toxicology screening of his blood or urine, or a psychiatric examination by a mental health professional, even though the patient reported a psychiatric history. The patient was not appropriately monitored and the patient eloped from the ED prior to 3:03 PM, and was unable to be found.

15. Record review of the hospital's on-call list showed that a Social Worker and Psychiatrist were on-call for the hospital while Patient #30 was in the ED.

Further review of hospital policy, "Patient Transfers and Emergency Medical treatment and Active Labor Act (EMTALA)", showed that for an individual with an emergency psychiatric condition, stabilized was defined as when the individual is protected and prevented from injuring himself or others during transfer or is no longer considered a threat to himself or others and therefore may be discharged. For the purposes of transferring a patient with a psychiatric condition from the hospital to another hospital, the patient is considered to be stable when he is protected and prevented from injuring himself or others.

16. Review of Patient #29's medical record showed that the patient presented by ambulance to the ED on Sunday 07/14/13 at 6:08 AM, with suicidal thoughts and a plan to hang himself with a belt. An ED physician examined the patient and cleared the patient for a mental health assessment. A social worker completed the mental health assessment and recommended inpatient psychiatric care for suicidal ideations with intent, and made arrangements for admission to Psychiatric Hospital C. The patient was not appropriately monitored and eloped before he was transferred.

Based on interview and record review, the hospital failed to provide an appropriate examination sufficient to determine whether an emergency medical condition existed for two patients (#1 and #30) out of 38 cases sampled from March through August, 2013. The Emergency Department (ED) sees an average of 2953 patients per month.

Findings included:

1. During an interview on 08/19/13 at 4:18 PM, Law Enforcement Officer GG stated that he responded to a call for Patient #1 on 07/30/13 at approximately 9:00 PM. Officer GG stated that the patient's words were slurred, he was swaying his body, could hardly walk, and had blood shot and watery eyes. Officer GG stated that the patient was so belligerent and intoxicated that he had to be placed in handcuffs "for everyone's safety". Officer GG stated that he requested an ambulance to take Patient #1 to St Luke's Hospital ED. "I was concerned about his safety and the safety of others around him, which is why he was taken to the hospital and not to jail. I thought he was too drunk to be safely in jail."

During an interview on 08/22/13 at 11:08 AM, Paramedic HH stated that when he transported Patient #1, who was homeless and with a psychiatric history, the patient smelled like alcohol, was yelling obscenities and spitting at the ambulance crew.

2. During an interview on 08/13/13 at 3:04 PM, Hospital Security Guard J stated that when Patient #1 arrived at St Luke's Hospital, he was agitated and smelled like alcohol. "I could tell that he was intoxicated" because of the way he was acting. Security Guard J stated that nursing staff asked him to handcuff one of the patient's hands to the gurney, and restrain the other hand to the gurney, which he did "for the safety of the staff and because they requested it." "When I tried to put the soft wrist restraint on the right arm, he tried to pull away from me. I felt he needed to be in restraints" because he was still agitated.

3. Review of Patient #1's medical record dated 07/30/13, showed that the patient arrived by ambulance at St Luke's Hospital ED at 9:35 PM for intoxication. Upon arrival, the patient was combative, verbally inappropriate, with increasing aggression, to the point that security was contacted and the patient was restrained and handcuffed to an ED gurney. The patient broke out of the restraint, drug the gurney over to the sink, removed the handcuff from his hand using soap, and attempted to elope, but was redirected back to the exam room by security. Physician documentation at 10:00 PM, showed that the patient was anxious and hostile, and that security remained at the patient's bedside. RN documentation showed that at 10:08 PM, security noted the patient was increasingly agitated and at 10:10 PM, the patient ran out of the exam room, and was directed out of the ED by security. St. Luke's Hospital of Kansas City is a level 1 trauma center equipped to provide comprehensive emergency medical services to patients. The hospital's capabilities include on call psychiatrists and social workers who perform mental health examinations. The medical record lacked evidence the patient received a mental health examination and toxicology testing of blood or urine to determine whether an emergency medical condition existed.

4. During an interview on 08/08/13 at 12:34 PM, ED RN F stated that when Patient #1 arrived, he was in handcuffs and was cursing to staff, using the "F word", and was unpredictable, aggressive and non-cooperative. "When we were telling him to calm down he would be aggressive. He would be calm and then he would just jerk and then become aggressive again. It was a high tense situation." RN F stated that she had other patients to take care of, so she didn't report Patient #1's behavior to the ED physician, and didn't reassess the patient before she observed him elope. "I saw him walking out of the front of the ED nurses station with the off duty officer." "There was a lot of people and a lot of commotion. Then the patient just left out of the front exit", while security walked with him. "I didn't ask the physician if it was safe for the patient to leave" "I didn't try to stop him. I didn't try to coax him back into the room. If a patient is going to leave then it's not my call. It's the physician's call to determine stability." RN F added that she gave the patient AMA (against medical advice) paperwork "because the physician felt that the patient would be safer staying at the hospital."

5. During an interview on 08/08/13 at approximately 9:30 AM, ED RN G stated that when the physician entered the Patient #1's exam room, the patient was pacing, "really restless", and security was in the room. RN G stated that the doctor asked the patient what he could do for him, if he was having pain and how much he had to drink. "He was under the influence of something, but not sure what." RN G stated that the physician asked the patient for five minutes and he would return with "paperwork", but the patient ran out of the room and eloped. "I think the doctor spoke with (RN F) and I think he told (RN F) to let the patient go because we did not retain him."


6. During an interview on 08/08/13 at 11:00 AM, ED Physician E made the following statements about Patient #1:
-He had received a ticket for drinking in public the night he was brought to the ED;
-Security was required to get him back into his exam room;
-He had a handcuff that was hanging from a rail on his gurney;
-He was "frustrated and had some frustration when he spoke";
-He repeatedly stated that he wanted to go home;
-He did not remain in his room when Physician F asked him to;
-He was hostile and anxious because he attempted to leave the ED two times;
-He "seemed appropriate as far as I saw" and "took direction very well";
-He was "safe to discharge";
-He was encouraged to stay in the ED "because he had been drinking";
-He was offered an AMA form to sign without the risks of leaving documented on it;
-He was escorted out by security.
Physician E stated that he was not aware of the patient's unpredictable aggression, because "everything happened so fast". "I can't explain why the patient behaved in the manner that he did", but Physician E stated that he did not request a mental health evaluation for the patient because "there wasn't time" and "because I didn't feel the guy needed it".


7. Review of on-call lists showed that a Psychiatrist and Social Worker were on-call (to perform mental health examinations) for the hospital while the patient was in the ED.


8. Review of hospital policy, "Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA)" dated 08/10, a Medical Screening Examination (MSE) as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. The MSE is an ongoing process and the medical record must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred.

9. During an interview on 08/13/13 at 1:42 PM, off-duty Officer K, functioning as hospital security in the ED on 07/30/13, stated that he overheard the Physician E say to Patient #1, "Wait right here and I will go and get the paperwork", so he "assumed the patient was discharged". Officer K stated that when Patient #1 walked out of his exam room, he gave the patient directions to the front door and "no one approached (Patient #1) and had him sign" the AMA paperwork. "They usually try to get the patient to stay so they can go over the paperwork with him, but no one stopped him and no one asked me to stop him."


10. During an interview on 08/08/13 at 12:11 PM, Hospital Security Guard I stated that he was working an outside security booth when he observed Officer K escort Patient #1 out of the building. Security Guard I stated that the patient disappeared out of sight, and was then observed driving a vehicle that struck another vehicle, drove over a median and hit a stop sign, and then drove away.

11. Review of law enforcement reports dated 07/30/13 and 07/31/13, showed that on 07/30/13, Patient #1 was observed driving a vehicle that struck another vehicle, struck a stop sign, and then drove off. Further review of the reports alleged that the patient abandoned the first vehicle (stolen by Patient #1), car-jacked a second vehicle, and crashed the second vehicle into a utility pole, causing Patient #1 significant injury that required hospitalization.

12. Review of an ambulance report dated 07/30/13, showed that EMS received a call at 10:33 PM, to respond to a motor vehicle accident involving Patient #1 (23 minutes after the patient was escorted out of St Luke's Hospital ED). The report showed that Patient #1 had a strong odor of alcohol on his breath, was found on the ground next to the driver's side of a vehicle that had struck a light pole and broke the pole in half. Patient #1 complained of right hip pain and was transported emergently by ambulance to Hospital B.

During an interview on 08/23/13 at 10:12 AM, Paramedic II stated that the ambulance responded to a motor vehicle accident involving Patient #1 (after he was discharged from St Luke's Hospital), who was suspected of driving a vehicle into a light pole and breaking it in half. Paramedic II stated that the patient was slurring his words and admitted to drinking, and was transported to Hospital B's ED for care of a possible fractured or dislocated hip, and possible internal bleeding.

13. Review of Patient #1's medical record from Hospital B, showed that the patient was received in the ED from EMS on 07/30/13 at 11:05 PM, with complaints of right hip pain.

Patient #30

14. Review of Patient #30's medical record showed that he presented to the ED by ambulance on 07/14/13 at 7:27 PM with alcoholism. ED RN V, triage nurse, documented the patient appeared intoxicated and had a history of drinking alcohol daily. Physician S documented this was the patient's fourth visit to the ED in 24 hours for uncontrolled substance abuse and intoxication. An application for a 96 hour hold was completed by Physician S and Social Worker W, because the patient "abuses alcohol" and "presents a likelihood of serious harm to himself" through repeated dangerous alcohol consumption, extreme intoxication with exposure to heat, patient deterioration over the last six months, and refusing substance abuse resources. The application was faxed to the Probate Court at 9:56 PM on 07/15/13. At 3:07 AM, while the 96 hour hold application was still in process, the patient eloped from the ED and could not be found. St. Luke's Hospital of Kansas City is a level 1 trauma center equipped to provide comprehensive emergency medical services to patients. The hospital's capabilities include on call psychiatrists and social workers who perform mental health examinations. The facility also has the capability to provide one-to-one observation to patients who are at risk for self harm or injury. The medical record lacked evidence the patient received a mental health examination or toxicology testing of blood or urine to determine whether an emergency medical condition existed, the patient was not properly monitored, and was allowed to elope from the ED.

During a telephone interview on 08/15/13 at 5:49 PM, Social Worker W stated that she completed a 96 hour hold application for Patient #30 because she thought the patient might die. Social Worker W stated that the patient was "extremely intoxicated" and his judgment and safety were impaired because of his continued drinking and exposure to extreme heat.


15. Review of the hospital policy, "Referral for Voluntary/Involuntary Commitment (96 Hour Hold)" dated 07/09, showed that a referral for Civil Involuntary Detention Process will be instituted for the detention of a patient for mental health treatment when the person exhibits behavior that indicates a mental disorder, illness or substance abuse problem. Further review showed that after it is determined that the likelihood of harm is present, the patient will be placed on one-to-one observation.

Review of the hospital's security log showed that security was notified 07/15/13 at 12:30 AM, that Patient #30 was on "hold/watch".

16. During a telephone interview on 08/14/13 at 8:30 AM, ED Physician S stated that she was confident the 96 hour hold application would be denied, so she wrote discharge orders for the patient at 10:46 PM (with a 96 hour hold application in process) and left her shift.

17. During an interview on 08/19/13 at 4:46 PM, Nurse V stated that Patient #30 arrived to the ED he smelled of alcohol, had slurred speech, difficulty concentrating, and was sluggish. Nurse V stated that he was not aware that a 96 hour hold was in process for the patient because no one told him, and if he would have known, he would have obtained a sitter to monitor the patient 1:1. Nurse V stated that the hospital didn't manage "drunk or violent" patients in the same manner that "suicidal or homicidal" patients were managed, and indicated that drunk or violent patients were not monitored with one-to-one observation for safety as suicidal or homicidal patients were, and because of this, the patient was able to elope from the ED without being seen.

18. Record review of an ambulance report dated 07/15/13 showed that EMS responded to Patient #30 at 8:52 AM, after the patient was found unresponsive with an empty bottle of vodka. The patient remained unresponsive after ambulance staff physically shook him and shouted at him, and the patient was transported to St. Luke's Hospital ED.

19. Record review of a medical record dated 07/15/13 showed that Patient #30 arrived to the ED by ambulance at 9:17 AM, after he was found intoxicated. ED RN documentation showed that the patient appeared intoxicated and sleepy and that his speech was slurred. Physician documentation showed that the patient was lethargic (slow to move or respond) was intoxicated, and had reported to ambulance staff that he drank 750 milliliters of alcohol that morning. Further physician documentation showed that the patient did not show functional capacity, but could be discharged to the care of a responsible adult. Prior to 1:35 PM, the patient eloped from the ED without the knowledge of staff. The facility has the capability to provide one-to-one observation to patients who are at risk for self harm or injury. The medical record lacked evidence the patient received a mental health examination or toxicology testing of blood or urine to determine whether an emergency medical condition existed, the patient was not properly monitored, and was allowed to elope from the ED.

18. Record review of an ambulance report dated 07/17/13 showed that EMS responded to Patient #30 at 12:22 PM, after local law enforcement found the patient on the sidewalk, complaining of abdominal pain and bleeding, and exposing his genitals several times. The patient, who was not alert, was transported to the St. Luke's Hospital ED.

19. Record review of a medical record dated 07/17/13, showed that Patient #30 arrived by ambulance to the ED at 1:09 PM, after the patient was "found intoxicated" by local law enforcement. ED Physician documentation showed that the patient had heavy alcohol use for a long time and that the patient had been in the ED four times over the previous three days. The physician also documented that the patient had a psychiatric history and alcohol abuse. There was no evidence that the patient received a psychiatric examination by a mental health professional and because the patient was not appropriately monitored, he eloped. and was unable to be found. St. Luke's Hospital of Kansas City is a level 1 trauma center equipped to provide comprehensive emergency medical services to patients. The medical record lacked evidence the patient received a mental health examination or toxicology testing of blood or urine to determine whether an emergency medical condition existed, the patient was not properly monitored, and was allowed to elope from the ED.

Based on interview and record review, the hospital failed to provide stabilizing treatment for an emergency medical condition for one patient (#29) out of 38 cases sampled from March through August, 2013. The Emergency Department (ED) sees an average of 2953 patients per month.

Findings included:

1. Review of Patient #29's medical record showed that the patient presented by ambulance to the ED on Sunday, 07/14/13 at 6:08 AM, with alcohol intoxication and suicidal thoughts. ED nurse documentation showed that the patient had a history of alcoholism, bipolar disorder and depression, and "is going to hang himself with a belt". Labs showed a blood alcohol level of 185 and a urine drug screen resulted positive for cocaine. ED Physician documentation showed that the patient had a suicidal plan to hang himself, so the patient was referred for a psychiatric assessment. Documentation of the psychiatric assessment showed that the patient's suicide risk was "strong ideation with intent", so inpatient psychiatric hospitalization was discussed with the patient, nurse, and physician, and arrangements were made to transfer the patient to Psychiatric Hospital C. Nurse documentation at 4:45 PM showed that the patient woke, was jittery and nervous, stated that he wasn't suicidal anymore, and wanted to smoke, so a Xanax (used to treat anxiety) was administered to the patient at 5:00 PM. There was no indication in the medical record that the patient was re-evaluated by a physician or a mental health professional after the patient indicated that he was no longer suicidal. At 5:40 PM, nurse documentation showed that the patient went to the bathroom and eloped and hospital security and local law enforcement were contacted, but the patient was unable to be found. St. Luke's Hospital of Kansas City is a level 1 trauma center equipped to provide comprehensive emergency medical services to patients. The hospital's capabilities include the ability to monitor one-to-one, patients who have been identified as a risk for self harm. The medical record lacked evidence that the patient, identified as having suicidal ideations, received appropriate monitoring, and the patient was allowed to elope from the ED prior to being transferred to an inpatient psychiatric facility for stabilization of his emergency medical condition.

2. During an interview on 08/15/13 at 11:57 AM, ED RN R, Charge Nurse, stated that she assumed care of Patient #29 the morning of 07/14/13, after the triage nurse reported that the patient would be evaluated for suicidal ideation when sober and was to be placed on close observation. Nurse R stated that at 3:00 PM, after the patient's psychiatric assessment was completed and Physician E was leaving his shift, the physician informed her that Patient #29 was suicidal, and at 4:00 PM, she contacted a local ambulance service for Patient #29's transfer to Psychiatric Hospital C. Nurse R stated that while the patient was in the ED he became agitated, so she requested an order for Xanax from Physician S, and administered it to the patient. Nurse R stated that she later assisted Patient #29 to the bathroom, left the patient unattended, and the patient eloped. Nurse R stated that she looked for the patient and then notified a nurse, Physician S, security, local law enforcement, and the receiving facility that the patient had eloped. Nurse R stated that because the patient never informed her directly that he wanted to kill himself, and because the physician didn't order one-to-one observation, she thought he was safe and didn't initiate one-to-one. Nurses R stated that a nurse can initiate one-to-one observation if they feel a patient needs it, by requesting a sitter from the staffing office. If the staffing office is unable to provide a sitter, then a staff member from the ED will sit with the patient and observe them one-to-one.

3. Review of the hospital policy, "Suicide Prevention (Constant/1:1 Observation)" dated 07/09, showed that all patients who are at risk for suicide/self harm will receive constant (one to one) observation and if the patient attempts to leave AMA and is at risk for self-harm, the RN should notify the physician, the charge nurse/nursing supervisor, the social worker and security.

4. . During a telephone interview on 08/15/13 at 10:59 AM, ED Physician E stated Patient #29 reported to him that he was going to hang himself, but did not know if the patient was observed one-to-one, because "the nursing staff were to take care of that." Physician E stated that he reported to and transferred care of the patient to on-coming Physician S, and informed her that the patient had suicidal ideations, alcohol consumption, and was awaiting placement at a psychiatric facility.

5. During a telephone interview on 08/19/12 at 2:18 PM, ED Physician S stated that a nurse spoke to her about Patient #29 and she was notified when the patient eloped, but did not remember anything about the patient because she did not see the patient or examine him. Physician S added that there were people who get drunk and say that they are going to "blow their head off", but it does not mean that they are suicidal, and may not need close or one-to-one observation, because each situation is different.

6. During an interview on 08/08/13 at 3:15 PM, Security Guard Q stated that if security was notified that a suicidal patient had eloped, she would obtain a description of the patient, relay the description to the security guards located outside of the hospital and contact local law enforcement to search for the patient. Security Guard Q verified there was no record of Patient #29's elopement on the Security log, or that law enforcement was notified.