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Based on observation, staff interview, document and video footage review, the Emergency Department (ED) Staff failed to provide an appropriate and ongoing medical screening exam (MSE) to 1 of 20 sampled patients (patient #1) presenting to the ED in the last six months from December 2015 to May 2016. The ED staff failed to complete an appropriate medical screening exam by not fully appreciating the patient's presentation and failed to protect his safety even though the ED staff was aware the patient had a history of dementia and had been identified as a flight risk (a person who is likely to flee). The patient eloped (walk away) from the ED and crossed busy streets with an IV (device used to access a blood vessel to deliver medications and/or fluids) still in place.

Failure to provide an appropriate medical screening exam and allowing patients to elope from the ED places patients at risk for harm and/or death.


Findings include:

- The hospital's policy for EMTALA reviewed on 5/18/2016 at 8:30 AM directed, "...the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. A Medical Screening Examination is not an isolated event. It is ongoing process that may begin, but typically does not end with triage..."

See further evidence at 2406

Based on observation, staff interview, document and video footage review, the Emergency Department (ED) Staff failed to provide an appropriate and ongoing medical screening exam (MSE) to 1 of 20 sampled patients (patient #1) presenting to the ED in the last six months from December 2015 to May 2016. The ED staff failed to protect patient # 1 even though the ED staff were aware the patient had presented with a history of dementia (gradual decrease of memory lost) and had been identified as a flight risk (a person who is likely to flee). The patient eloped (walk away) from the ED and crossed busy streets with an IV (device used to access a blood vessel to deliver medications and/or fluids) still in place.

Failure to provide an appropriate medical screening exam and allowing patients to elope from the ED places patients at risk for harm and/or death.

Findings include:

Skilled Nursing Facility (SNF) Administrator BB interviewed by phone on 5/18/2016 at 9:40 AM indicated they arranged to transfer patient #1 to Shawnee Mission Medical Center (SMMC) at approximately 6:10 PM on 5/9/16 because he had a low hemoglobin. The SNF Charge nurse faxed patient #1's health information to SMMC. SNF Administrator BB stated that patient # 1's family member called the SNF at 8:10 PM and told the nurse in charge that patient #1 was at their house. The SNF called SMMC to verify that patient #1 was not at their hospital.

Review of the Ambulance run report revealed an ambulance was requested to transport Patient #1 to SMMC on 5/9/2016 at 5:30 PM. The ambulance personnel documented patient #1 had a diagnosis of Alzheimer's (a progressive disease that destroys memory and other mental functions) and had become increasingly agitated and difficult to manager over the past few days. The ambulance personnel performed an EKG (a test used to measure the hearts rhythm) and inserted an intravenous (IV) catheter to access blood for testing and to administer IV fluids. Patient # 1 arrived at the SMMC emergency department (ED) at 6:35 PM and Paramedic EE gave report to ED nurse B.

Review of the ED medical record revealed patient # 1 presented to the ED at SMMC at 6:35 PM. ED nurse B obtained patient # 1's vital signs and Physician F examined the patient and noted the patient's history of dementia and low hemoglobin (oxygen carrying capacity of the blood). At 6:46 PM blood for testing was collected and plans for placement in an observation bed were initiated. The medical record did not contain documentation on patient #1's care and treatment from 6:39 PM until 9:22 PM. The hospital Medical Surgical floor log sheet revealed patient #1 arrived back at the hospital and was taken directly to an observation bed on the medical / surgical floor at 9:47 PM on 5/9/16. Patient # 1 was assigned a sitter for the remainder of his stay at the hospital.

Review of SMMC ' s Video surveillance showed the following:
6:35 PM on 5/9/16, Patient #1 arrived via ambulance through the ambulance entrance attached to the ED. Patient # 1 had an IV (device used to access a blood vessel to allow medication and/or fluid administration) with a bag of fluid attached to the IV line going to the patient.

7:07 PM- Patient #1 left ED room 9 wearing a red coat and walking past the information administration desk, the nursing station, and past the ambulance entrance.

7:10 PM- Patient #1 walked past the locked triage rooms, the triage desk at the main ED entrance, and continued walking down the hallway.

7:11 PM- 7:17PM - Patient #1 walked to a main lobby and was standing near two courtesy phones (unable to determine if patient used the telephone).

7:17 PM - Patient #1 walked out of the hospital and onto 74th street.

7:18 PM- 7:23 PM- Patient #1 was no longer in view of hospital cameras.

7:23 PM- 7:24 PM- Patient #1 was observed walking down the sidewalk near the life dynamics parking lot at the corner of 75th St and Kessler. The patient then walked across the four-lane street.

7:25 PM- Patient #1 no longer in camera views.

ED nurse B interviewed on 5/16/16 at 3:00 PM indicated patient #1 presented to the ED with ambulance personnel and was told that the patient was a flight risk and to keep eye on him. ED nurse B stated that Patient #1 seemed a little agitated but tucked the patient in bed before leaving the patient's room. ED nurse B said that patient # 1 stated he did not need to be at the hospital, that he had a low hemoglobin for some time. ED nurse B reported to ED nurse E when changing shifts, that patient #1 was a flight risk and suggested to get a gown on patient #1. No family was with patient #1 but the patient mentioned their significant other would be coming.

Medical Director C interviewed on 5/17/2016 at 9:25 AM indicated the hospital does not have a badge to place on a patient if they are a flight risk, and "does not have a policy as far as I know." Medical Director C indicated patients usually are placed in a gown as soon as possible. Medical Director C stated the hospital has enough sitters to provide to our patients if indicated.

ED nurse E interviewed on 5/17/16 at 2:00 PM indicated ED nurse B gave a verbal report about patient # 1 as the shift was ending. ED nurse B reported that patient #1 was alert and oriented, with a monitor on and that he was a flight risk. ED nurse E left the ED to transfer another patient to the floor. ED nurse E estimated s/he was out of the ED for 20 minutes. As ED nurse E passed Patient #1's room s/he noticed the patient was gone. ED nurse E immediately notified Charge Nurse G, and called security. "Staff H and I started to look around everywhere and security arrived and we nurses gave the description of Patient #1 and what he was wearing." "While this was all happening, Patient #1's Skilled Nursing Facility called telling us family member AA got a call from a neighbor and that Patient #1 was at their house." Eventually patient #1 was brought back to the hospital.

Physician F interviewed on 5/17/2016 at 3:00 PM indicated s/he remembers patient #1 came from a dementia unit in Paola, Kansas and was a flight risk. " Flight risk was put on our board. " "We first were planning to put patient # 1 in a locked unit due to the flight risk but the patient needed to be monitored." "Patient # 1 was placed in a room closest to the front desk. " Physician F remembers verifying patient #1's labs, placing orders to admit him and had closed patient #1's chart. ED nurse E notified physician F that patient #1 could not be found and security was called. Charge Nurse G notified the police. Physician F mentioned that ED nurse E spoke to a family member on the phone shortly after the patient was found at their house and were planning to have patient come back to the hospital. Physician F did not think of reopening the chart to document since s/he had already closed it.

ED Charge Nurse G interviewed on 5/17/2016 at 3:30 PM indicated that ED nurse E notified them that patient #1 left the hospital and security was notified. Charge nurse G was told patient #1 had come to the hospital by EMS from a nursing home and that ED nurse E said that patient #1 was alert and oriented, had been known to just leave, and was a flight risk. This did not raise a red flag that the patient needed a sitter. Charge nurse G instructed ED nurse E to notify the police department and to fill out an incident report. We did not know if patient #1 took a taxi, left with family or who took him.

ED nurse H interviewed at 5/17/2016 at 3:50 PM mentioned EMS gave report to ED nurse B. Patient #1came from a skilled nursing facility. EMS reported that patient #1 wanders at times. ED nurse B and H got patient #1 undressed and placed into a gown. ED nurse H wondered if they should keep patient #1's belongings in his room. ED nurse H said patient #1 was really with it, alert and oriented to time, place and person. ED nurse H was told by ED nurse E that they were going to take another patient up to the floor and would be right back. ED nurse H stated they checked on patient #1 and he did not want to watch TV so nurse H closed the door per the patient's request. When nurse E came back to the ED they asked nurse H where their patient went, patient #1's clothes were gone and the patient's gown was on the bed. Nurse H said that patient #1 did not seem confused, they were alert and oriented to time, place and person.

House Supervisor I interviewed on 5/18/2016 at 8:00 AM indicated they were told by the ED Charge nurse, G, that patient #1 had eloped from the ED. Supervisor I was told patient #1 had dementia and a low hemoglobin. Supervisor I stated s/he was not informed that patient #1was a flight risk.

House Supervisor J interviewed on 5/18/2016 at 8:00 AM indicated they came on shift at 11:00 PM and received report that the ED had a patient eloped. Patient #1 was found and came back to the hospital. Supervisor J did respond to the patient's room on a rapid response while patient #1 was receiving a blood transfusion. Afterwards, patient #1 was transferred to the Critical Care Unit.

Director of Emergency Services A interviewed on 5/16/16 and 5/19/2016 at 11:00 AM indicated they were not aware patient #1 had left their facility the evening of 5/9/2016. The nurse or charge nurse of their department is to report any incidents in the electronic "Risk Master." Any "Risk Master" reports go directly to Director A. Director A stated they usually only receives calls at home if a situation is critical, otherwise the Charge Nurse and House Supervisors are responsible.

Based on observation, staff interview, document and video footage review, the Emergency Department (ED) Staff failed to provide an appropriate and ongoing medical screening exam (MSE) to 1 of 20 sampled patients (patient #1) presenting to the ED in the last six months from December 2015 to May 2016. The ED staff failed to protect patient # 1 even though the ED staff were aware the patient had presented with a history of dementia (gradual decrease of memory lost) and had been identified as a flight risk (a person who is likely to flee). The patient eloped (walk away) from the ED and crossed busy streets with an IV (device used to access a blood vessel to deliver medications and/or fluids) still in place.

Failure to provide an appropriate medical screening exam and allowing patients to elope from the ED places patients at risk for harm and/or death.

Findings include:

Skilled Nursing Facility (SNF) Administrator BB interviewed by phone on 5/18/2016 at 9:40 AM indicated they arranged to transfer patient #1 to Shawnee Mission Medical Center (SMMC) at approximately 6:10 PM on 5/9/16 because he had a low hemoglobin. The SNF Charge nurse faxed patient #1's health information to SMMC. SNF Administrator BB stated that patient # 1's family member called the SNF at 8:10 PM and told the nurse in charge that patient #1 was at their house. The SNF called SMMC to verify that patient #1 was not at their hospital.

Review of the Ambulance run report revealed an ambulance was requested to transport Patient #1 to SMMC on 5/9/2016 at 5:30 PM. The ambulance personnel documented patient #1 had a diagnosis of Alzheimer's (a progressive disease that destroys memory and other mental functions) and had become increasingly agitated and difficult to manager over the past few days. The ambulance personnel performed an EKG (a test used to measure the hearts rhythm) and inserted an intravenous (IV) catheter to access blood for testing and to administer IV fluids. Patient # 1 arrived at the SMMC emergency department (ED) at 6:35 PM and Paramedic EE gave report to ED nurse B.

Review of the ED medical record revealed patient # 1 presented to the ED at SMMC at 6:35 PM. ED nurse B obtained patient # 1's vital signs and Physician F examined the patient and noted the patient's history of dementia and low hemoglobin (oxygen carrying capacity of the blood). At 6:46 PM blood for testing was collected and plans for placement in an observation bed were initiated. The medical record did not contain documentation on patient #1's care and treatment from 6:39 PM until 9:22 PM. The hospital Medical Surgical floor log sheet revealed patient #1 arrived back at the hospital and was taken directly to an observation bed on the medical / surgical floor at 9:47 PM on 5/9/16. Patient # 1 was assigned a sitter for the remainder of his stay at the hospital.

Review of SMMC ' s Video surveillance showed the following:
6:35 PM on 5/9/16, Patient #1 arrived via ambulance through the ambulance entrance attached to the ED. Patient # 1 had an IV (device used to access a blood vessel to allow medication and/or fluid administration) with a bag of fluid attached to the IV line going to the patient.

7:07 PM- Patient #1 left ED room 9 wearing a red coat and walking past the information administration desk, the nursing station, and past the ambulance entrance.

7:10 PM- Patient #1 walked past the locked triage rooms, the triage desk at the main ED entrance, and continued walking down the hallway.

7:11 PM- 7:17PM - Patient #1 walked to a main lobby and was standing near two courtesy phones (unable to determine if patient used the telephone).

7:17 PM - Patient #1 walked out of the hospital and onto 74th street.

7:18 PM- 7:23 PM- Patient #1 was no longer in view of hospital cameras.

7:23 PM- 7:24 PM- Patient #1 was observed walking down the sidewalk near the life dynamics parking lot at the corner of 75th St and Kessler. The patient then walked across the four-lane street.

7:25 PM- Patient #1 no longer in camera views.

ED nurse B interviewed on 5/16/16 at 3:00 PM indicated patient #1 presented to the ED with ambulance personnel and was told that the patient was a flight risk and to keep eye on him. ED nurse B stated that Patient #1 seemed a little agitated but tucked the patient in bed before leaving the patient's room. ED nurse B said that patient # 1 stated he did not need to be at the hospital, that he had a low hemoglobin for some time. ED nurse B reported to ED nurse E when changing shifts, that patient #1 was a flight risk and suggested to get a gown on patient #1. No family was with patient #1 but the patient mentioned their significant other would be coming.

Medical Director C interviewed on 5/17/2016 at 9:25 AM indicated the hospital does not have a badge to place on a patient if they are a flight risk, and "does not have a policy as far as I know." Medical Director C indicated patients usually are placed in a gown as soon as possible. Medical Director C stated the hospital has enough sitters to provide to our patients if indicated.

ED nurse E interviewed on 5/17/16 at 2:00 PM indicated ED nurse B gave a verbal report about patient # 1 as the shift was ending. ED nurse B reported that patient #1 was alert and oriented, with a monitor on and that he was a flight risk. ED nurse E left the ED to transfer another patient to the floor. ED nurse E estimated s/he was out of the ED for 20 minutes. As ED nurse E passed Patient #1's room s/he noticed the patient was gone. ED nurse E immediately notified Charge Nurse G, and called security. "Staff H and I started to look around everywhere and security arrived and we nurses gave the description of Patient #1 and what he was wearing." "While this was all happening, Patient #1's Skilled Nursing Facility called telling us family member AA got a call from a neighbor and that Patient #1 was at their house." Eventually patient #1 was brought back to the hospital.

Physician F interviewed on 5/17/2016 at 3:00 PM indicated s/he remembers patient #1 came from a dementia unit in Paola, Kansas and was a flight risk. " Flight risk was put on our board. " "We first were planning to put patient # 1 in a locked unit due to the flight risk but the patient needed to be monitored." "Patient # 1 was placed in a room closest to the front desk. " Physician F remembers verifying patient #1's labs, placing orders to admit him and had closed patient #1's chart. ED nurse E notified physician F that patient #1 could not be found and security was called. Charge Nurse G notified the police. Physician F mentioned that ED nurse E spoke to a family member on the phone shortly after the patient was found at their house and were planning to have patient come back to the hospital. Physician F did not think of reopening the chart to document since s/he had already closed it.

ED Charge Nurse G interviewed on 5/17/2016 at 3:30 PM indicated that ED nurse E notified them that patient #1 left the hospital and security was notified. Charge nurse G was told patient #1 had come to the hospital by EMS from a nursing home and that ED nurse E said that patient #1 was alert and oriented, had been known to just leave, and was a flight risk. This did not raise a red flag that the patient needed a sitter. Charge nurse G instructed ED nurse E to notify the police department and to fill out an incident report. We did not know if patient #1 took a taxi, left with family or who took him.

ED nurse H interviewed at 5/17/2016 at 3:50 PM mentioned EMS gave report to ED nurse B. Patient #1came from a skilled nursing facility. EMS reported that patient #1 wanders at times. ED nurse B and H got patient #1 undressed and placed into a gown. ED nurse H wondered if they should keep patient #1's belongings in his room. ED nurse H said patient #1 was really with it, alert and oriented to time, place and person. ED nurse H was told by ED nurse E that they were going to take another patient up to the floor and would be right back. ED nurse H stated they checked on patient #1 and he did not want to watch TV so nurse H closed the door per the patient's request. Wh