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Based on interview, record review and policy review, the hospital failed to follow their policies to identify an emergency medical condition (EMC) and to provide a safe, appropriate discharge for one patient (#1) out of 31 Emergency Department (ED) records reviewed for patients that presented to the ED from 07/05/24 through 01/13/25.

These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 6,943.

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," showed any individual who comes to the ED of this hospital shall receive a MSE performed by Qualified Medical Personnel (QMP) to determine whether that individual is experiencing an EMC. The MSE shall be appropriate to the individual's signs and symptoms, as well as the capability and capacity of the hospital. ED staff shall attempt interventions with any individual indicating a desire to leave the ED prior to receiving a MSE. ED staff shall advise an individual indicating a desire to leave of the risks of refusing a MSE and assess that individual's capacity to understand those risks. If staff are concerned the individual has a psychiatric (relating to mental illness) disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, staff should implement the policy "Medical Holds for Psychiatric Patient Safety" and staff may request assistance from Security. Disruptive, inappropriate, or erratic behavior may be an indication of an underlying EMC, and QMP must carefully assess the patient's capacity to understand the situation and information provided.

Review of the hospital's undated policy titled, "Rules and Regulations of the Medical Staff," showed that members of the medical staff shall comply with the NKCH policy entitled "Emergency Medical Screening, Treatment, Transfer and On-Call Roster." In accordance with the policy and federal law, all individuals who come to the hospital's ED shall receive a MSE by a QMP, will be provided stabilizing treatment and, when necessary, an appropriate transfer.

Review of the hospital's undated policy titled, "Medical Holds for Psychiatric Patient Safety," showed NKCH Medical Staff Members or Nursing Staff shall designate patients as being on a Medical Hold status when the patient presents a likelihood of serious harm to themselves or others. The determination of whether a patient is likely to harm him/herself or others shall be based on clinical assessment and may be due to a patient's psychiatric disturbance or substance abuse. A patient on a medical hold is not permitted to leave against medical advice (AMA) and should be required to stay at NKCH using the least restrictive means. This may include, but is not limited to, initiating the restraint usage policy or direct observation where appropriate, and/or requesting assistance from Security. A medical hold is a designation to help assure patient safety and is not a legal process and does not require a court order. When a patient appears to have a psychiatric disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, nursing staff should confirm that a physician has assessed the patient's medical stability and has requested a psychiatric evaluation. Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by a Behavioral Health Assessor or by a psychiatrist (physician who specializes in mental health disorders). NKCH staff caring for psychiatric patients and others present at the hospital with personal knowledge of the patient's condition or behavior (such as friends and family, first responders, and law enforcement) should complete the Department of Mental Health form 142 Affidavit (a written statement confirmed by oath, for use as evidence in court). Staff should facilitate the completion of affidavits by others present at the hospital with personal knowledge of the patient's condition. The presence of an affidavit on the medical record does not automatically mean that the patient is on a medical hold. An affidavit is not required to be on the medical record to detain a patient at NKCH for the patient's safety.

Review of the hospital's undated policy titled, "Care of the Suicidal/Homicidal/Unsafe Patient," showed that staff should follow this policy when providing to care for unsafe patients, including patients with behavioral health/psychiatric complaints, suicidal ideation (SI, thoughts of causing one's own death), homicidal ideation (HI, thoughts or attempts to cause another's death), or substance abuse problems. The goal is to provide the safest environment possible and to minimize the potential for harm to the patient, visitors, staff, and others. Indications that a patient has SI, HI, or is unsafe may include a report from an ambulance crew, other transporters or observation of patient's verbal and/or behaviors. Certain symptoms or disorders may provide indications that a patient is or may become SI, HI, or unsafe. Symptoms/disorders which can lead to SI/HI include disorientation (experiencing delusions or hallucinations) and defiance (wanting complete control of oneself). The staff member who first receives information regarding a patient's SI or HI, or concerns for other behavioral health conditions, shall be responsible for documenting and alerting other staff. ED patients presenting with behavioral health conditions as their primary reason for care will have a suicidal screening performed on every encounter using the Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS combined with clinical judgement can help determine levels of risk and aid in making clinical decisions about care.

Review of the hospital's undated policy titled, "Security & Safety - Security Responsibilities," showed Security staff should:
- Patrol the facility, adjacent parking areas and premises;
- Assist patients, visitors, and employees in reasonable requests for service or guidance;
- Be alert for and document potentially hazardous situations and conditions on hospital premises and within the facilities;
- Maintain vigilance for unsafe acts, events or situations; and
- Assist with transfer to the hospital of personnel who cannot get to the hospital during inclement weather.

Review of the hospital's undated policy titled, "Security," showed that the hospital's Security staff provides protection for employees, patients and visitors. Security also monitors the hospital's buildings, equipment, and supplies, and is alert to potentially hazardous situations or conditions. Security officers patrol the facilities, adjacent parking areas, and premises to assist employees, patients, and visitors. Security and safety are the responsibility of every NKCH staff member. For the welfare of patients, visitors and fellow employees, all staff should be alert to the presence of suspicious persons, particularly in unauthorized areas; suspicious activity of any nature; unusual findings or incidents; and circumstances which look out of place. The Security staff should be notified immediately in the event of such occurrences.

Review of the hospital's undated policy titled, "ED - Discharge of Patient from the Emergency Department," showed that the ED follows the general guidelines for the discharge of a patient from the hospital.

Review of the hospital's undated policy titled, "Discharge," showed that a discharge plan is developed based on individual needs and discussed with the patient and/or caregiver. The nurse will review discharge instructions with the patient. Any patient requiring transportation from the hospital must have documentation from case management and/or the Director of Clinical Operations. Discharge considerations for winter weather included a winter storm warning (heavy snow of six inches in 12 hours or eight inches in 24 hours, or sleet of one-half inch or more) and/or a blizzard warning (blizzard conditions for at least three hours).


47504

Based on interview, record review and policy review, the hospital failed to follow their policies to identify an emergency medical condition (EMC) for a one patient (#1) out of 31 Emergency Department (ED) records reviewed for patients that presented to the ED from 07/05/24 through 01/13/25.
These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 6,943.

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," showed any individual who comes to the ED of this hospital shall receive a MSE performed by Qualified Medical Personnel (QMP) to determine whether that individual is experiencing an EMC. The MSE shall be appropriate to the individual's signs and symptoms, as well as the capability and capacity of the hospital. ED staff shall attempt interventions with any individual indicating a desire to leave the ED prior to receiving a MSE. ED staff shall advise an individual indicating a desire to leave of the risks of refusing a MSE and assess that individual's capacity to understand those risks. If staff are concerned the individual has a psychiatric (relating to mental illness) disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, staff should implement the policy "Medical Holds for Psychiatric Patient Safety" and staff may request assistance from Security. Disruptive, inappropriate, or erratic behavior may be an indication of an underlying EMC, and QMP must carefully assess the patient's capacity to understand the situation and information provided.

Review of the hospital's undated policy titled, "Rules and Regulations of the Medical Staff," showed that members of the medical staff shall comply with the NKCH policy entitled "Emergency Medical Screening, Treatment, Transfer and On-Call Roster." In accordance with the policy and federal law, all individuals who come to the hospital's ED shall receive a MSE by a QMP, will be provided stabilizing treatment and, when necessary, an appropriate transfer.

Review of the hospital's undated policy titled, "Medical Holds for Psychiatric Patient Safety," showed NKCH Medical Staff Members or Nursing Staff shall designate patients as being on a Medical Hold status when the patient presents a likelihood of serious harm to themselves or others. The determination of whether a patient is likely to harm him/herself or others shall be based on clinical assessment and may be due to a patient's psychiatric disturbance or substance abuse. A patient on a medical hold is not permitted to leave against medical advice (AMA) and should be required to stay at NKCH using the least restrictive means. This may include, but is not limited to, initiating the restraint usage policy or direct observation where appropriate, and/or requesting assistance from Security. A medical hold is a designation to help assure patient safety and is not a legal process and does not require a court order. When a patient appears to have a psychiatric disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, nursing staff should confirm that a physician has assessed the patient's medical stability and has requested a psychiatric evaluation. Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by a Behavioral Health Assessor or by a psychiatrist (physician who specializes in mental health disorders). NKCH staff caring for psychiatric patients and others present at the hospital with personal knowledge of the patient's condition or behavior (such as friends and family, first responders, and law enforcement) should complete the Department of Mental Health form 142 Affidavit (a written statement confirmed by oath, for use as evidence in court). Staff should facilitate the completion of affidavits by others present at the hospital with personal knowledge of the patient's condition. The presence of an affidavit on the medical record does not automatically mean that the patient is on a medical hold. An affidavit is not required to be on the medical record to detain a patient at NKCH for the patient's safety.

Review of the hospital's undated policy titled, "Care of the Suicidal/Homicidal/Unsafe Patient," showed that staff should follow this policy when providing to care for unsafe patients, including patients with behavioral health/psychiatric complaints, suicidal ideation (SI, thoughts of causing one's own death), homicidal ideation (HI, thoughts or attempts to cause another's death), or substance abuse problems. The goal is to provide the safest environment possible and to minimize the potential for harm to the patient, visitors, staff, and others. Indications that a patient has SI, HI, or is unsafe may include a report from an ambulance crew, other transporters or observation of patient's verbal and/or behaviors. Certain symptoms or disorders may provide indications that a patient is or may become SI, HI, or unsafe. Symptoms/disorders which can lead to SI/HI include disorientation (experiencing delusions[false ideas about what is taking place or who one is] or hallucinations [seeing or hearing things which are not there]) and defiance (wanting complete control of oneself). The staff member who first receives information regarding a patient's SI or HI, or concerns for other behavioral health conditions, shall be responsible for documenting and alerting other staff. ED patients presenting with behavioral health conditions as their primary reason for care will have a suicidal screening performed on every encounter using the Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS combined with clinical judgement can help determine levels of risk and aid in making clinical decisions about care.

Review of the hospital's undated policy titled, "Security & Safety - Security Responsibilities," showed Security staff should:
- Patrol the facility, adjacent parking areas and premises;
- Assist patients, visitors, and employees in reasonable requests for service or guidance;
- Be alert for and document potentially hazardous situations or conditions on hospital premises and within the facilities;
- Maintain vigilance for unsafe acts, events or situations; and
- Assist with transfers to the hospital during inclement weather.

Review of the hospital's undated policy titled, "Security," showed that the hospital's Security staff provides protection for employees, patients and visitors. Security also monitors the hospital's buildings, equipment, and supplies, and is alert to potentially hazardous situations or conditions. Security officers patrol the facilities, adjacent parking areas, and premises to assist employees, patients, and visitors. Security and safety are the responsibility of every NKCH staff member. For the welfare of patients, visitors and fellow employees, all staff should be alert to the presence of suspicious persons, particularly in unauthorized areas; suspicious activity of any nature; unusual findings or incidents; and circumstances which look out of place. The Security staff should be notified immediately in the event of such occurrences.

Review of Police Department D's report, titled "Offense/Incident Report," dated 01/05/25, related to Patient #1, showed that Staff LL, Corporal for Police Department D, was dispatched on 01/05/25 at approximately 11:11 AM to a casino regarding a female who was trespassing. Upon arrival, he was contacted by security who advised that the female claimed to work there, was trying to access employee only areas, she seemed confused and believed the casino was Costco. Staff LL contacted the female (Patient #1). She was very abrasive and refused to answer questions. She did state that she thought it was 2024, Friday, that she was in Kansas City, and that the casino was or used to be a Costco. Patient #1 appeared to be suffering from some form of mental health issue that limited her ability to answer questions correctly or to know where she was. Patient #1 was clearly in a delusional state of mind. EMS was requested for Patient #1 due to her failure to answer questions in conjunction with the winter storm which limited her ability to go anywhere safely. Patient #1 persistently refused to answer questions and was physically forced onto the stretcher for transportation to the hospital. Staff used a firm grip when assisting her onto the stretcher. She was clearly upset but appeared to understand the need to cooperate with Fire Department B. She was transferred to NKCH without any other incidents. It was unclear as to how she came to be at the casino. She claimed to have driven, but due to the winter storm, it seemed unlikely.

Review of Fire Department C's EMS record, related to Patient #1, dated 01/05/25, showed that EMS was dispatched to the casino for a patient with an altered mental status (mental functioning ranging from slight confusion to coma). Multiple Police Department D units were on scene prior to EMS arrival. Patient #1 was found standing upright in the exit atrium area of the casino. She presented as alert and oriented to self only. She was able to speak and answer some questions appropriately. Police Department D told EMS that the patient had been there for approximately six hours and was disoriented to where she was. She repeatedly told police that she thought the casino was a "Costco" and that her house was at the casino. She refused to answer any orientation questions or allow EMS to obtain any vital signs (VS, measurements of the body's most basic functions). She continued being uncooperative, despite many attempts by EMS and law enforcement attempts to initiate care. Casino security told the police that they did not want her on the property. This was relayed to the patient, she was informed that if she did not accept care, she could be arrested. Fire Department B EMS arrived on scene and her care was transferred to their staff. The attending medic was given a summary of the patient's complaints, findings, and treatments. Patient #1 continued to be uncooperative. Eventually, a decision was made to place her in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and to transport her to the hospital due to her altered mental status. Police Department D was able to maneuver her to the stretcher. Once she was on the stretcher, she calmed down and no restraints were needed. Her physical assessment indicated no abnormal findings. Her Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 14. The EMS primary impression was excited (agitated) delirium (an abrupt change in the brain that causes confusion). Patient #1 was transported by Fire Department B EMS to NKCH.

Review of Fire Department B's EMS record, related to Patient #1, dated 01/05/28, showed that EMS was dispatched to the casino along with Fire Department C and Police Department D for a reported behavioral health issue. The patient was confused/disoriented and not wanting to cooperate with Fire, EMS, or Police. Casino security reported making contact with Patient #1 at approximately 6:00 AM. She was observed via a security camera attempting to go into restricted areas of the casino, cleaning the restroom, and reporting to security that she was an employee. Upon arrival, Patient #1 was found to be walking on scene, agitated, anxious, angry/upset, not making any sense, and her thought process was all over the place. She was alert and talking but did not want to answer any questions for EMS. Her physical assessment showed no abnormal physical findings. Her VS were within normal limits. Her GCS was 14. She was mentally unstable, and Police Department D staff had to physically assist her on to the stretcher. She did not want to be transported and reported that she was perfectly fine. Once she was placed on the stretcher, she was secured, monitored and transported to NKCH.

Review of Patient #1's ED record, dated 01/05/25, showed the following:
- She was a 63-year-old female with no past medical history listed. Her sister was listed as an emergency contact, but there was no working telephone number listed.
- The pre-arrival report sheet noted that Patient #1 was found wandering around the casino, was angry, and her vital signs were stable.
- Bedside report indicated that she had been walking outside and had no complaints. There was no medical history, allergies, medications and/or drug or alcohol use listed.
- Neither the pre-arrival nor the bedside report indicated that Patient #1 was confused.
- On 01/05/25 at 12:23 PM, she was brought in via EMS after being found walking around the casino.
- At 12:27 PM, Staff T, ED RN, documented that Patient #1 was found wandering around the casino, was kicked out, and became angry. She had no complaints at that time and denied SI and HI. Her temperature was slightly elevated at 99.5 degrees along with her blood pressure of 158/98. She denied any pain. Her C-SSRS score was zero and her GCS was 15.
- At 12:39 PM, Staff U, ED Physician, documented that Patient #1 had no medical complaints. She was upset she was there. She was somewhat confused and would not give him a definitive reason why she was at the casino that morning. It was not clear how she got to the casino or why she went there in the first place. She was alert and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). She knew she was at the hospital, she told Staff U her address which matched the one listed on her driver's license. She did leave the house that morning, and she lived at home with her dog and cat. She did not want to have anything done in the ED and requested that they help her get home. Her speech was normal, her movements were coordinated, and her cognition appeared normal. Her VS were within normal limits. She was able to answer all of Staff U's other questions appropriately. Documentation indicated that Staff U did not believe that the hospital had the right to hold her down and/or force medical care on her. This included laboratory testing and obtaining a urinalysis (a laboratory examination of a person's urine). She did not appear to be under the influence of any drugs or alcohol, she exhibited no acute hallucinations, delusions, or psychosis (mental illness characterized by defective or lost contact with reality).
- At 1:05 PM, Staff T, ED RN, documented that Patient #1 was discharged to home. Her BP was slightly elevated at 159/91, her GCS was 15 and she denied any pain.
- Her total length of stay in the ED was 42 minutes.

Review of the hospital's event report titled, "Current Summary," dated 01/07/25, showed that on 01/06/25 at 7:40 AM, Staff CC, Cardiac Progressive Care Unit (PCU, a telemetry [remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring) RN, was alerted by the wife of Patient #30 to a questionable object outside of Patient #30's window. Staff CC saw what appeared to be a long dark object, but visibility was low. Staff CC notified security and asked them to check on the suspicious object. She explained to security that the shape resembled a body and it looked out of place. Security indicated that they would send someone to check. Two hours later, Staff CC entered into Patient #31's room to pass medications and perform an assessment. Patient #31 was standing by the window and looking out. She asked Staff CC what she thought was on the ground. The light was better at that time. Staff CC looked out and clearly saw a body lying on their right side in the snow. The body did not move. Staff CC called security again, at 9:45 AM. She informed them that she had called earlier, but no one had checked on the situation. There were no tracks in the snow and the object was clearly a body. The security guard stated that they would send someone to check.

Review of the hospital's security report titled, "Incident Report," dated 01/07/25 at 11:45 AM, showed on 01/06/25 at approximately 9:39 AM, Staff D, Security Officer, was dispatched to the Professional Building for a reported person down. Staff CC, Cardiac PCU RN, reported observing, from the 10th floor Cardiac PCU, what she believed was a person lying in the snow. Upon his arrival, Staff D noticed a person lying on the ground near the electrical boxes below the handicap parking, near the building. The person appeared to be without signs of life. He called out to the individual without response and tapped her on the shoulder. She felt cold to the touch and solid as if rigor mortis (stiffening of the joints and muscles of the body a few hours after death) had set in. Staff D notified Staff EE, Security Dayshift Sergeant, of the situation and requested that EMS and Police Department E be called. EMS responded and found no vital signs and no signs of life. Staff EE notified Staff X, Director of Clinical Operations, and the Security Supervisor. Staff D remained at the scene until Police Department E arrived. The medical examiner removed Patient #1's body at approximately 12:45 PM. Staff Y, Lead Ground Maintenance, stated he observed Patient #1 near the main entrance appearing to attempt to get into the building on 01/05/25 at approximately 2:50 PM. Security video review showed Patient #1 coming out of triage with a nurse. Patient #1 entered security's vehicle and was dropped off at the bus stop located on the hospital's campus. Several buses had come and gone. When security dropped off another discharged patient at the bus stop, they appeared to check on Patient #1, that was between 1:06 PM and 1:45 PM. At 1:47 PM, Patient #1 walked down to the area near the Professional Building, where she was later found. At 1:50 PM, Patient #1 appeared to attempt to enter the main entrance of the Professional Building. At 1:52 PM, she walked back down to the area near the Professional Building. Between 1:52 PM and 9:16 PM, Patient #1 paced back and forth around the Professional Building near the electrical boxes. From 9:16 PM to 11:15 PM, Patient #1 lay on the ground moving. At 11:15 PM, Patient #1 moved for the last time. It was noted that Patient #1 was outside in what appeared to be heavy snow and blizzard like conditions. A supplemental report, dated 01/06/25 at 5:00 PM, Staff EE, Security Dayshift Sergeant, was instructed by the Security Supervisor to return to the scene of the incident to attempt to locate Patient #1's purse. He located a grate that was ajar on the south side of the Professional Building. He looked down the shaft, below the grate and discovered a purse at 5:17 PM. Staff EE retrieved the purse. Two IDs were also found in the pit. A Plant Operations employee used a small ladder to retrieve them. On 01/07/25 at 11:02 AM, Staff II, Chief of Security, and a detective from Police Department E arrived at the security office, where the detective took possession of the purse.

Review of Police Department D's report, titled "Offense/Incident Report," dated 01/06/25, showed that at 4:27 PM, Staff JJ, Police Department D Officer, was traveling northbound on Missouri Highway 69 crossing the Missouri River when he observed a dark vehicle in the ditch off Tremont Trafficway. While in route to check on the vehicle, he was notified by communications that Police Department E was requesting an area check of the casino for a vehicle. He advised communications that the vehicle he noted and was traveling to partially matched the provided description. Upon arrival, he confirmed the vehicle description and that the license plate matched the description of the vehicle that Police Department E had provided. The front end of the vehicle was in a ditch, with only the rear of the vehicle sticking up. At the request of his sergeant, he looked through the vehicle's windows for Patient #1's purse and cellular telephone. He did not see anything matching the provided description and he did not open the vehicle. He contacted a tow company and the vehicle was transported to a storage facility.

Review of Police Department E's report titled, "Offense/Incident Report," dated 01/06/23, showed the following:
- Staff EE, Security Dayshift Sergeant, contacted the police department regarding a potential deceased individual. Multiple police officers responded to the scene while Fire Department B checked for signs of life. At 9:54 AM, Patient #1 was pronounced deceased. The initial responding Police Officer stated that Staff D, Security Officer, was advised by a staff nurse that there was a body lying in the snow outside. The body was found lying in the snow, on the east side of 2700 Clay Edwards Drive, south of the retaining wall. Staff D nudged the body with his foot and realized she was stiff to touch. He notified his supervisor. The time of the notification was not noted in the report. There appeared to be no obvious signs of trauma. Patient #1 had a medical bracelet on from North Kansas City Hospital that was dated 01/05/25. From 01/05/25 into 01/06/25, there were freezing temperatures and blizzard like conditions. The police officer was advised by Staff EE that Patient #1 had been brought to the hospital at approximately 12:23 PM on 01/05/25, by EMS from a local casino. She had been discharged on 01/05/25 at 1:05 PM.
- Staff OO, Detective, arrived on the scene to initiate an investigation. He notified Patient #1's sister of her death. During their interview, Patient #1's sister stated that Patient #1 worked at Costco. Her normal working hours were 4:30 AM to 2:00 PM. She had been employed at Costco for approximately 20 years. Patient #1 did not gamble and it was "odd" that she was at the casino. Patient #1 had been previously diagnosed with a form of dementia (a loss of thinking abilities and memory).
- Staff OO contacted Police Department D for additional information. Patient #1 had been found by casino security wandering around and attempting to get into restricted areas. She was combative and refused to leave, so security called the police. Dispatch stated that Police Department D had been dispatched to the casino at 11:11 AM and that Fire Department B had been dispatched at 12:00 PM. Patient #1 was transported for altered mental status to North Kansas City Hospital by Fire Department B. Staff OO reviewed the body camera footage of the officers that responded to the casino, which showed that Patient #1 was confused as to where she was and thought she was at Costco. Her vehicle was found off the roadway in a ditch about three to four blocks from the casino.
- Staff OO, contacted Costco, Patient #1's place of employment. Management acknowledged that Patient #1 had some memory issues. At times, she did not know where she was while at work, failed to clock in or out, and at times did not know what she was doing at work.
- On 01/06/25 at 5:45 PM, Staff OO was notified that Patient #1's purse was found, 25 yards away from where her body had been located, sitting on a grate. The contents of the purse had spilled down into the area beneath the grate.
- On 01/07/25 at 9:00 AM, an interview was conducted with Staff CC, Cardiac PCU RN. She stated that Patient #30's wife had asked her to look out the window to identify an object. It was dark outside, but she saw a rectangular object in the grass. She notified security regarding the object at 7:43 AM. A couple of hours later, the sun was up, and she could clearly see that the object was a body lying in the grass. She notified security again at 9:43 AM. She did not observe anyone near the body.
- On 01/07/25 at 10:45 AM, Staff OO reviewed the video of Patient #1's movements while on hospital property. Security provided a ride for Patient #1 and several other patients, to the bus stop around 1:00 PM. A short time later, when a bus arrived, she did not get on the bus. Patient #1 remained at the bus stop with several other people. Security returned and according to interview, Patient #1 failed to accept a ride to a gas station down the road, where another bus stop was located. Security transported some of the others in their vehicle and Patient #1remained standing at the bus stop alone. A short time later, security returned to the bus stop and was offered a blanket, but she declined. Patient #1 remained at the bus stop. She eventually made her way to the area where she was later found deceased. She was observed walking around that small area for the remainder of the day. She did approach the front doors of the 2700 building and was observed communicating with a person within a snow removal vehicle. Patient #1 then walked back down to the area where she was found, wandering around until 11:00 PM. At approximately 9:00 PM, Patient #1 laid down on the ground, where she was later found. She was observed lying on the ground, moving her arms and legs. rolling from side to side. She did not get up from that position and stopped moving at approximately 11:00 PM.
- On 01/07/25 at 12:28 PM, an interview was conducted with Patient #31. Patient #31's room was the last one on the hall, with two windows facing 2700 Clay Edwards Drive. She reported that on 01/05/25 at approximately 9:30 PM, she observed someone walking around in the snow outside of 2700 Clay Edwards Drive building. She informed her nurse, described as a black female with an accent, that someone was walking around in the cold weather. She stated the nurse notified security regarding the individual. When Patient #31 awoke on 01/06/25 at approximately 6:10 AM, she observed what appeared to be a body lying on the ground. She then notified Staff CC of the body. She also spoke with Patient #30's wife who also observed the body lying on the ground. She did not observe security in the area, where the body was found, until approximately 9:40 AM. Security had been notified multiple times that someone was walking around in the cold and that Patient #1's body was lying in the snow.

Review of the hospital's document titled, "North Kansas City Hospital Emergency Department Activity Log," from 01/04/25 to 01/06/25, showed the following:
- On 01/04/25, there were a total of 175 patients seen in the ED.
- On 01/05/25, there were a total of 68 patients seen in the ED.
- On 01/06/25, there were a total of 168 patients seen in the ED.

Review of the hospital's document titled, "Security Dispatch Log," from 01/03/25 to 01/07/25, showed no documentation of any phone calls to security, on 01/05/25 or 01/06/25, regarding Patient #1.

Review of the hospital's document titled, "Security and Safety Shift Summary," dated 01/06/25, showed on 01/05/25, from 1:05 PM to 2:10 PM, security staff transported multiple individuals to the bus stop on the hospital's campus and the bus stop at a nearby gas station. There was no documentation of any phone calls regarding Patient #1 wandering outside the Professional Building.

Review of the hospital's document titled, "Security and Safety Shift Summary," dated 01/07/25, showed on 01/06/25, from 7:42 AM to 8:50 AM, nine homeless discharged patients were escorted from the triage area to the cafeteria, then transported to the bus stop. At 9:41 AM, a call was received regarding a downed person. At 5:00 PM, the Security Supervisor initiated a property search. The property was located and secured. There was no documentation of any phone calls to security regarding Patient #1 lying in the snow, outside the Professional Building.

Review of the National Weather Service almanac for Kansas City, Missouri, showed that on 01/05/25, the lowest temperature was 12° F, with the highest temperature of 22° F, wind chills as low as 15 below zero, and 11 inches of snowfall.

Observation on 01/15/24 at 11:20 AM, from the 10th floor PCU window, showed a view of the 2700 Clay Edwards Drive building and the bus stop down the street. There were handicap parking spaces to the left of the entrance of the building, then a retaining wall and railing. Below the retaining wall was a flat area, in front of a row of windows, with an electrical transformer near the building. An additional wall blocked the view from the road. Per Staff A, Chief Operating Officer (COO), Patient #1 was found behind the additional wall, near the electrical transformer.

Observation on 01/15/25 at 11:40 AM, at the bus stop where Patient #1 was dropped off, showed a significant distance between the bus stop and where Patient #1's body was found. A State Surveyor and Staff A, COO, stood approximately where Patient #1's body was found, near the electrical transformer, while another State Surveyor and Staff B, Vice President of Quality, stood at the bus stop. When looking from the bus stop toward where Patient #1's body was found, it was very difficult to see the State Surveyor and Staff A, standing next to the electrical transformer, due to the distance, terrain and snowfall. From the bus stop, it was impossible to see anything on the ground next to the State Surveyor and Staff A, due to the terrain and snowfall.

During a telephone interview on 01/22/25, Staff LL, Corporal for Police Department D, stated that on 01/05/25, he was called to the casino. The casino manager reported that Patient #1 was trying to get into secured areas, claimed that she worked there, and then thought she was at Costco. Patient #1 was not an employee at the casino. He spoke with Patient #1, and she was "obviously confused and not well oriented." Patient #1 did not want to fully identify herself or to provide any family phone numbers. She "got every mental health question wrong." She had no obvious trauma or injuries. She was dressed appropriately for walking out to the car, but not appropriately dressed for being outside for a long period of time. Patient #1 "was not capable of making her own decisions." She thought Staff LL "was harassing her at her house," and "seemed very confused" about who Staff LL was. Staff LL was unable to locate Patient #1's car in the casino parking lot. He thought "something's wrong here," and called EMS for a mental health assessment. EMS arrived and assessed the patient. She did not want EMS to do anything and refused to let them take her blood pressure or check her blood glucose. He was told by EMS that if Patient #1 couldn't answer four basic questions, they would have to take her to the hospital. Staff LL and the EMS crew observed the same symptoms that Patient #1 was exhibiting. She was escorted to the stretcher, and he removed Patient #1's ID from her purse. He located a phone number for the patient's son. Staff LL then called and left Patient #1's son a message. Staff LL stated that the police "only fill out affidavits if patients are suicidal or a harm to themselves or others for a 96-hour hold."

During a telephone interview on 01/23/25, Staff MM, Fire Department C Lieutenant and Paramedic, stated that Police Department D requested EMS to the casino. Patient #1 could talk; she was confused and thought the casino was Costco. Later, Patient #1 thought that she was in her house. She was dressed in jeans and a jacket, which was weather appropriate. She "was definitely confused, but somewhat with it." She started to walk out of the casino, made it about five yards out the door, then was redirected by Staff MM, who was able to convince her to return inside. Fire Department C did not have an ambulance, so Fire Department B was contacted to send an ambulance. Staff MM and the police officers tried to get Patient #1 to go to the hospital, but she was not cooperating. It "got to the point" where Staff MM asked the police officers if Patient #1 was going to be arrested for trespassing since she was uncooperative. After that, Patient #1 was guided onto the stretcher. Staff MM stated that he did not normally fill out affidavits, they were usually completed by law enforcement.

During a telephone interview on 02/26/25 at 11:55 AM, Staff NN, Fire Department B Firefighter and Paramedic, stated that he was dispatched to the casino where Fire Department C and Police Department D were already on scene. When he arrived, Police Department D officers were arguing with the patient at one of the casino entrances. Patient #1 "was not making any sense, and her thought process was all over the place." She was saying "erratic" stuff. She kept saying that they had been to her home numerous times, she kept re

Based on interview, record review and policy review, the hospital failed to follow their policy to ensure a safe discharge for one patient (#1) out of 31 Emergency Department (ED) records reviewed for patients that presented to the ED from 07/05/24 through 01/13/25.

This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 6,943.

Findings included:

Review of the hospital's undated policy titled, "Security & Safety - Security Responsibilities," showed Security staff should:
- Patrol the facility, adjacent parking areas and premises;
- Assist patients, visitors, and employees in reasonable requests for service or guidance;
- Be alert for and document potentially hazardous situations or conditions on hospital premises and within the facilities;
- Maintain vigilance for unsafe acts, events or situations; and
- Assist with transfers to the hospital during inclement weather.

Review of the hospital's undated policy titled, "Security," showed that the hospital's Security staff provides protection for employees, patients and visitors. Security also monitors the hospital's buildings, equipment, and supplies, and is alert to potentially hazardous situations or conditions. Security officers patrol the facilities, adjacent parking areas, and premises to assist employees, patients, and visitors. Security and safety are the responsibility of every NKCH staff member. For the welfare of patients, visitors and fellow employees, all staff should be alert to the presence of suspicious persons, particularly in unauthorized areas; suspicious activity of any nature; unusual findings or incidents; and circumstances which look out of place. The Security staff should be notified immediately in the event of such occurrences.

Review of the hospital's undated policy titled, "ED - Discharge of Patient from the Emergency Department," showed that the ED follows the general guidelines for discharge of a patient from the hospital.

Review of the hospital's undated policy titled, "Discharge," showed that a discharge plan is developed based on individual needs and discussed with the patient and/or caregiver. The nurse will review discharge instructions with the patient. Any patient requiring transportation from the hospital must have documentation from case management and/or the Director of Clinical Operations. Discharge considerations for winter weather included a winter storm warning (heavy snow of six inches in 12 hours or eight inches in 24 hours, or sleet of one-half inch or more) and/or a blizzard warning (blizzard conditions for at least three hours).

Review of Police Department D's report, titled "Offense/Incident Report," dated 01/05/25, related to Patient #1, showed that Staff LL, Corporal for Police Department D, was dispatched on 01/05/25 at approximately 11:11 AM to a casino regarding a female who was trespassing. Upon arrival, he was contacted by security who advised that the female claimed to work there, was trying to access employee only areas, she seemed confused and believed the casino was Costco. Staff LL contacted the female (Patient #1). She was very abrasive and refused to answer questions. She did state that she thought it was 2024, Friday, that she was in Kansas City, and that the casino was or used to be a Costco. Patient #1 appeared to be suffering from some form of mental health issue that limited her ability to answer questions correctly or to know where she was. Patient #1 was clearly in a delusional state of mind. EMS was requested for Patient #1 due to her failure to answer questions in conjunction with the winter storm which limited her ability to go anywhere safely. Patient #1 persistently refused to answer questions and was physically forced onto the stretcher for transportation to the hospital. Staff used a firm grip when assisting her onto the stretcher. She was clearly upset but appeared to understand the need to cooperate with Fire Department B. She was transferred to NKCH without any other incidents. It was unclear as to how she came to be at the casino. She claimed to have driven, but due to the winter storm, it seemed unlikely.

Review of Fire Department C's EMS record, related to Patient #1, dated 01/05/25, showed that EMS was dispatched to the casino for a patient with an altered mental status (mental functioning ranging from slight confusion to coma). Multiple Police Department D units were on scene prior to EMS arrival. Patient #1 was found standing upright in the exit atrium area of the casino. She presented as alert and oriented to self only. She was able to speak and answer some questions appropriately. Police Department D told EMS that the patient had been there for approximately six hours and was disoriented to where she was. She repeatedly told police that she thought the casino was a "Costco" and that her house was at the casino. She refused to answer any orientation questions or allow EMS to obtain any vital signs (VS, measurements of the body's most basic functions). She continued being uncooperative, despite many attempts by EMS and law enforcement attempts to initiate care. Casino security told the police that they did not want her on the property. This was relayed to the patient, she was informed that if she did not accept care, she could be arrested. Fire Department B EMS arrived on scene and her care was transferred to their staff. The attending medic was given a summary of the patient's complaints, findings, and treatments. Patient #1 continued to be uncooperative. Eventually, a decision was made to place her in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and to transport her to the hospital due to her altered mental status. Police Department D was able to maneuver her to the stretcher. Once she was on the stretcher, she calmed down and no restraints were needed. Her physical assessment indicated no abnormal findings. Her Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 14. The EMS primary impression was excited (agitated) delirium (an abrupt change in the brain that causes confusion). Patient #1 was transported by Fire Department B EMS to NKCH.

Review of Fire Department B's EMS record, related to Patient #1, dated 01/05/28, showed that EMS was dispatched to the casino along with Fire Department C and Police Department D for a reported behavioral health issue. The patient was confused/disoriented and not wanting to cooperate with Fire, EMS, or Police. Casino security reported making contact with Patient #1 at approximately 6:00 AM. She was observed via a security camera attempting to go into restricted areas of the casino, cleaning the restroom, and reporting to security that she was an employee. Upon arrival, Patient #1 was found to be walking on scene, agitated, anxious, angry/upset, not making any sense, and her thought process was all over the place. She was alert and talking but did not want to answer any questions for EMS. Her physical assessment showed no abnormal physical findings. Her VS were within normal limits. Her GCS was 14. She was mentally unstable, and Police Department D staff had to physically assist her on to the stretcher. She did not want to be transported and reported that she was perfectly fine. Once she was placed on the stretcher, she was secured, monitored and transported to NKCH.

Review of Patient #1's ED record, dated 01/05/25, showed the following:
- She was a 63-year-old female with no past medical history listed. Her sister was listed as an emergency contact, but there was no working telephone number listed.
- The pre-arrival report sheet noted that Patient #1 was found wandering around the casino, was angry, and her vital signs were stable.
- Bedside report indicated that she had been walking outside and had no complaints. There was no medical history, allergies, medications and/or drug or alcohol use listed.
- Neither the pre-arrival nor the bedside report indicated that Patient #1 was confused.
- On 01/05/25 at 12:23 PM, she was brought in via EMS after being found walking around the casino.
- At 12:27 PM, Staff T, ED RN, documented that Patient #1 was found wandering around the casino, was kicked out, and became angry. She had no complaints at that time and denied SI and HI. Her temperature was slightly elevated at 99.5 degrees along with her blood pressure of 158/98. She denied any pain. Her C-SSRS score was zero and her GCS was 15.
- At 12:39 PM, Staff U, ED Physician, documented that Patient #1 had no medical complaints. She was upset she was there. She was somewhat confused and would not give him a definitive reason why she was at the casino that morning. It was not clear how she got to the casino or why she went there in the first place. She was alert and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). She knew she was at the hospital, she told Staff U her address which matched the one listed on her driver's license. She did leave the house that morning, and she lived at home with her dog and cat. She did not want to have anything done in the ED and requested that they help her get home. Her speech was normal, her movements were coordinated, and her cognition appeared normal. Her VS were within normal limits. She was able to answer all of Staff U's other questions appropriately. Documentation indicated that Staff U did not believe that the hospital had the right to hold her down and/or force medical care on her. This included laboratory testing and obtaining a urinalysis (a laboratory examination of a person's urine). She did not appear to be under the influence of any drugs or alcohol, she exhibited no acute hallucinations, delusions, or psychosis (mental illness characterized by defective or lost contact with reality).
- At 1:05 PM, Staff T, ED RN, documented that Patient #1 was discharged to home. Her BP was slightly elevated at 159/91, her GCS was 15 and she denied any pain.
- Her total length of stay in the ED was 42 minutes.

Review of Patient #1's EMS record from Fire Department B showed that EMS was dispatched on 01/05/25. Upon arrival to the casino, Fire Department C and Police Department D reported some type of behavioral health issue going on because the patient was confused/disoriented and not wanting to cooperate with Fire, EMS, or Police. Casino security reported making contact with the patient at approximately 6:00 AM because she was seen through a security camera attempting to go into restricted areas of the casino, cleaning the restroom, and reporting to security that she was an employee. Upon arrival, the patient was found to be walking on scene, agitated, anxious, angry/upset, not making any sense, her thought process was all over the place. She was alert, talking and did not want to answer any questions for EMS. Her physical assessment showed no abnormal physical findings. Her vital signs were within normal limits. Her GCS was 14. She was mentally unstable, and Police Department D had to force her on to the cot, because she did not want to be transported and reported that she was perfectly fine. She was placed on the cot, secured, monitored and transported to NKCH.

Review of the hospital's event report titled, "Current Summary," dated 01/07/25, showed that on 01/06/25 at 7:40 AM, Staff CC, Cardiac Progressive Care Unit (PCU, a telemetry [remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring) RN, was alerted by the wife of Patient #30 to a questionable object outside of Patient #30's window. Staff CC saw what appeared to be a long dark object, but visibility was low. Staff CC notified security and asked them to check on the suspicious object. She explained to security that the shape resembled a body and it looked out of place. Security indicated that they would send someone to check. Two hours later, Staff CC entered into Patient #31's room to pass medications and perform an assessment. Patient #31 was standing by the window and looking out. She asked Staff CC what she thought was on the ground. The light was better at that time. Staff CC looked out and clearly saw a body lying on their right side in the snow. The body did not move. Staff CC called security again, at 9:45 AM. She informed them that she had called earlier, but no one had checked on the situation. There were no tracks in the snow and the object was clearly a body. The security guard stated that they would send someone to check.

Review of the hospital's security report titled, "Incident Report," dated 01/07/25 at 11:45 AM, showed on 01/06/25 at approximately 9:39 AM, Staff D, Security Officer, was dispatched to the Professional Building for a reported person down. Staff CC, Cardiac PCU RN, reported observing, from the 10th floor Cardiac PCU, what she believed was a person lying in the snow. Upon his arrival, Staff D noticed a person lying on the ground near the electrical boxes below the handicap parking, near the building. The person appeared to be without signs of life. He called out to the individual without response and tapped her on the shoulder. She felt cold to the touch and solid as if rigor mortis (stiffening of the joints and muscles of the body a few hours after death) had set in. Staff D notified Staff EE, Security Dayshift Sergeant, of the situation and requested that EMS and Police Department E be called. EMS responded and found no vital signs and no signs of life. Staff EE notified Staff X, Director of Clinical Operations, and the Security Supervisor. Staff D remained at the scene until Police Department E arrived. The medical examiner removed Patient #1's body at approximately 12:45 PM. Staff Y, Lead Ground Maintenance, stated he observed Patient #1 near the main entrance appearing to attempt to get into the building on 01/05/25 at approximately 2:50 PM. Security video review showed Patient #1 coming out of triage with a nurse. Patient #1 entered security's vehicle and was dropped off at the bus stop located on the hospital's campus. Several buses had come and gone. When security dropped off another discharged patient at the bus stop, they appeared to check on Patient #1, that was between 1:06 PM and 1:45 PM. At 1:47 PM, Patient #1 walked down to the area near the Professional Building, where she was later found. At 1:50 PM, Patient #1 appeared to attempt to enter the main entrance of the Professional Building. At 1:52 PM, she walked back down to the area near the Professional Building. Between 1:52 PM and 9:16 PM, Patient #1 paced back and forth around the Professional Building near the electrical boxes. From 9:16 PM to 11:15 PM, Patient #1 lay on the ground moving. At 11:15 PM, Patient #1 moved for the last time. It was noted that Patient #1 was outside in what appeared to be heavy snow and blizzard like conditions. A supplemental report, dated 01/06/25 at 5:00 PM, Staff EE, Security Dayshift Sergeant, was instructed by the Security Supervisor to return to the scene of the incident to attempt to locate Patient #1's purse. He located a grate that was ajar on the south side of the Professional Building. He looked down the shaft, below the grate and discovered a purse at 5:17 PM. Staff EE retrieved the purse. Two IDs were also found in the pit. A Plant Operations employee used a small ladder to retrieve them. On 01/07/25 at 11:02 AM, Staff II, Chief of Security, and a detective from Police Department E arrived at the security office, where the detective took possession of the purse.

Review of Police Department D's report, titled "Offense/Incident Report," dated 01/06/25, showed that at 4:27 PM, Staff JJ, Police Department D Officer, was traveling northbound on Missouri Highway 69 crossing the Missouri River when he observed a dark vehicle in the ditch off Tremont Trafficway. While in route to check on the vehicle, he was notified by communications that Police Department E was requesting an area check of the casino for a vehicle. He advised communications that the vehicle he noted and was traveling to partially matched the provided description. Upon arrival, he confirmed the vehicle description and that the license plate matched the description of the vehicle that Police Department E had provided. The front end of the vehicle was in a ditch, with only the rear of the vehicle sticking up. At the request of his sergeant, he looked through the vehicle's windows for Patient #1's purse and cellular telephone. He did not see anything matching the provided description and he did not open the vehicle. He contacted a tow company and the vehicle was transported to a storage facility.

Review of Police Department E's report titled, "Offense/Incident Report," dated 01/06/23, showed the following:
- Staff EE, Security Dayshift Sergeant, contacted the police department regarding a potential deceased individual. Multiple police officers responded to the scene while Fire Department B checked for signs of life. At 9:54 AM, Patient #1 was pronounced deceased. The initial responding Police Officer stated that Staff D, Security Officer, was advised by a staff nurse that there was a body lying in the snow outside. The body was found lying in the snow, on the east side of 2700 Clay Edwards Drive, south of the retaining wall. Staff D nudged the body with his foot and realized she was stiff to touch. He notified his supervisor. The time of the notification was not noted in the report. There appeared to be no obvious signs of trauma. Patient #1 had a medical bracelet on from North Kansas City Hospital that was dated 01/05/25. From 01/05/25 into 01/06/25, there were freezing temperatures and blizzard like conditions. The police officer was advised by Staff EE that Patient #1 had been brought to the hospital at approximately 12:23 PM on 01/05/25, by EMS from a local casino. She had been discharged on 01/05/25 at 1:05 PM.
- Staff OO, Detective, arrived on the scene to initiate an investigation. He notified Patient #1's sister of her death. During their interview, Patient #1's sister stated that Patient #1 worked at Costco. Her normal working hours were 4:30 AM to 2:00 PM. She had been employed at Costco for approximately 20 years. Patient #1 did not gamble and it was "odd" that she was at the casino. Patient #1 had been previously diagnosed with a form of dementia (a loss of thinking abilities and memory).
- Staff OO contacted Police Department D for additional information. Patient #1 had been found by casino security wandering around and attempting to get into restricted areas. She was combative and refused to leave, so security called the police. Dispatch stated that Police Department D had been dispatched to the casino at 11:11 AM and that Fire Department B had been dispatched at 12:00 PM. Patient #1 was transported for altered mental status to North Kansas City Hospital by Fire Department B. Staff OO reviewed the body camera footage of the officers that responded to the casino, which showed that Patient #1 was confused as to where she was and thought she was at Costco. Her vehicle was found off the roadway in a ditch about three to four blocks from the casino.
- Staff OO, contacted Costco, Patient #1's place of employment. Management acknowledged that Patient #1 had some memory issues. At times, she did not know where she was while at work, failed to clock in or out, and at times did not know what she was doing at work.
- On 01/06/25 at 5:45 PM, Staff OO was notified that Patient #1's purse was found, 25 yards away from where her body had been located, sitting on a grate. The contents of the purse had spilled down into the area beneath the grate.
- On 01/07/25 at 9:00 AM, an interview was conducted with Staff CC, Cardiac PCU RN. She stated that Patient #30's wife had asked her to look out the window to identify an object. It was dark outside, but she saw a rectangular object in the grass. She notified security regarding the object at 7:43 AM. A couple of hours later, the sun was up, and she could clearly see that the object was a body lying in the grass. She notified security again at 9:43 AM. She did not observe anyone near the body.
- On 01/07/25 at 10:45 AM, Staff OO reviewed the video of Patient #1's movements while on hospital property. Security provided a ride for Patient #1 and several other patients, to the bus stop around 1:00 PM. A short time later, when a bus arrived, she did not get on the bus. Patient #1 remained at the bus stop with several other people. Security returned and according to interview, Patient #1 failed to accept a ride to a gas station down the road, where another bus stop was located. Security transported some of the others in their vehicle and Patient #1remained standing at the bus stop alone. A short time later, security returned to the bus stop and was offered a blanket, but she declined. Patient #1 remained at the bus stop. She eventually made her way to the area where she was later found deceased. She was observed walking around that small area for the remainder of the day. She did approach the front doors of the 2700 building and was observed communicating with a person within a snow removal vehicle. Patient #1 then walked back down to the area where she was found, wandering around until 11:00 PM. At approximately 9:00 PM, Patient #1 laid down on the ground, where she was later found. She was observed lying on the ground, moving her arms and legs. rolling from side to side. She did not get up from that position and stopped moving at approximately 11:00 PM.
- On 01/07/25 at 12:28 PM, an interview was conducted with Patient #31. Patient #31's room was the last one on the hall, with two windows facing 2700 Clay Edwards Drive. She reported that on 01/05/25 at approximately 9:30 PM, she observed someone walking around in the snow outside of 2700 Clay Edwards Drive building. She informed her nurse, described as a black female with an accent, that someone was walking around in the cold weather. She stated the nurse notified security regarding the individual. When Patient #31 awoke on 01/06/25 at approximately 6:10 AM, she observed what appeared to be a body lying on the ground. She then notified Staff CC of the body. She also spoke with Patient #30's wife who also observed the body lying on the ground. She did not observe security in the area, where the body was found, until approximately 9:40 AM. Security had been notified multiple times that someone was walking around in the cold and that Patient #1's body was lying in the snow.

Review of the hospital's document titled, "North Kansas City Hospital Emergency Department Activity Log," from 01/04/25 to 01/06/25, showed the following:
- On 01/04/25, there were a total of 175 patients seen in the ED.
- On 01/05/25, there were a total of 68 patients seen in the ED.
- On 01/06/25, there were a total of 168 patients seen in the ED.

Review of the hospital's document titled, "Security Dispatch Log," from 01/03/25 to 01/07/25, showed no documentation of any phone calls to security, on 01/05/25 or 01/06/25, regarding Patient #1.

Review of the hospital's document titled, "Security and Safety Shift Summary," dated 01/06/25, showed on 01/05/25, from 1:05 PM to 2:10 PM, security staff transported multiple individuals to the bus stop on the hospital's campus and the bus stop at a nearby gas station. There was no documentation of any phone calls regarding Patient #1 wandering outside the Professional Building.
Review of the hospital's document titled, "Security and Safety Shift Summary," dated 01/07/25, showed on 01/06/25, from 7:42 AM to 8:50 AM, nine homeless discharged patients were escorted from the triage area to the cafeteria, then transported to the bus stop. At 9:41 AM, a call was received regarding a downed person. At 5:00 PM, the Security Supervisor initiated a property search. The property was located and secured. There was no documentation of any phone calls to security regarding Patient #1 lying in the snow, outside the Professional Building.

Review of the National Weather Service almanac for Kansas City, Missouri, showed that on 01/05/25, the lowest temperature was 12° F, with the highest temperature of 22° F, wind chills as low as 15 below zero, and 11 inches of snowfall.

Observation on 01/15/24 at 11:20 AM, from the 10th floor PCU window, showed a view of the 2700 Clay Edwards Drive building and the bus stop down the street. There were handicap parking spaces to the left of the entrance of the building, then a retaining wall and railing. Below the retaining wall was a flat area, in front of a row of windows, with an electrical transformer near the building. An additional wall blocked the view from the road. Per Staff A, Chief Operating Officer (COO), Patient #1 was found behind the additional wall, near the electrical transformer.

Observation on 01/15/25 at 11:40 AM, at the bus stop where Patient #1 was dropped off, showed a significant distance between the bus stop and where Patient #1's body was found. A State Surveyor and Staff A, COO, stood approximately where Patient #1's body was found, near the electrical transformer, while another State Surveyor and Staff B, Vice President of Quality, stood at the bus stop. When looking from the bus stop toward where Patient #1's body was found, it was very difficult to see the State Surveyor and Staff A, standing next to the electrical transformer, due to the distance, terrain and snowfall. From the bus stop, it was impossible to see anything on the ground next to the State Surveyor and Staff A, due to the terrain and snowfall.

During a telephone interview on 01/22/25, Staff LL, Corporal for Police Department D, stated that on 01/05/25, he was called to the casino. The casino manager reported that Patient #1 was trying to get into secured areas, claimed that she worked there, and then thought she was at Costco. Patient #1 was not an employee at the casino. He spoke with Patient #1, and she was "obviously confused and not well oriented." Patient #1 did not want to fully identify herself or to provide any family phone numbers. She "got every mental health question wrong." She had no obvious trauma or injuries. She was dressed appropriately for walking out to the car, but not appropriately dressed for being outside for a long period of time. Patient #1 "was not capable of making her own decisions." She thought Staff LL "was harassing her at her house," and "seemed very confused" about who Staff LL was. Staff LL was unable to locate Patient #1's car in the casino parking lot. He thought "something's wrong here," and called EMS for a mental health assessment. EMS arrived and assessed the patient. She did not want EMS to do anything and refused to let them take her blood pressure or check her blood glucose. He was told by EMS that if Patient #1 couldn't answer four basic questions, they would have to take her to the hospital. Staff LL and the EMS crew observed the same symptoms that Patient #1 was exhibiting. She was escorted to the stretcher, and he removed Patient #1's ID from her purse. He located a phone number for the patient's son. Staff LL then called and left Patient #1's son a message. Staff LL stated that the police "only fill out affidavits if patients are suicidal or a harm to themselves or others for a 96-hour hold."

During a telephone interview on 01/23/25, Staff MM, Fire Department C Lieutenant and Paramedic, stated that Police Department D requested EMS to the casino. Patient #1 could talk; she was confused and thought the casino was Costco. Later, Patient #1 thought that she was in her house. She was dressed in jeans and a jacket, which was weather appropriate. She "was definitely confused, but somewhat with it." She started to walk out of the casino, made it about five yards out the door, then was redirected by Staff MM, who was able to convince her to return inside. Fire Department C did not have an ambulance, so Fire Department B was contacted to send an ambulance. Staff MM and the police officers tried to get Patient #1 to go to the hospital, but she was not cooperating. It "got to the point" where Staff MM asked the police officers if Patient #1 was going to be arrested for trespassing since she was uncooperative. After that, Patient #1 was guided onto the stretcher. Staff MM stated that he did not normally fill out affidavits, they were usually completed by law enforcement.

During a telephone interview on 02/26/25 at 11:55 AM, Staff NN, Fire Department B Firefighter and Paramedic, stated that he was dispatched to the casino where Fire Department C and Police Department D were already on scene. When he arrived, Police Department D officers were arguing with the patient at one of the casino entrances. Patient #1 "was not making any sense, and her thought process was all over the place." She was saying "erratic" stuff. She kept saying that they had been to her home numerous times, she kept repeating herself and would not answer questions. Casino staff reported that she had been "roaming the casino since 6:00 AM that morning," trying to clean the restrooms and to access restricted areas. Patient #1 was not employed at the casino. There were red flags that "she was not there." She was arguing and did not want to go to the hospital. Staff NN requested Police Department D officers to assist her to the stretcher. Once on the stretcher, she was transported to North Kansas City Hospital. While in route, she remained uncooperative. Staff NN "was not able to get a straight answer" from her. He provided a radio report to the ED and informed the nurse about Patient #1's abnormal behaviors. When they arrived at the ED, they transferred the patient to a hospital bed and he provided a bedside report to the nurse which detailed her abnormal behaviors. Patient #1 continued to exhibit the same symptoms during the bedside report that she was exhibiting at the casino. There were no affidavits completed regarding Patient #1. Staff NN stated that if a patient constantly fought and did not want to be transported to the hospital, he would have the police officers complete an affidavit or have them respond to the ED with the patient.

During an interview on 01/14/25 at 3:20 PM, Staff T, ED RN, stated that she was the nurse for Patient #1. Patient #1 arrived at the ED via EMS. She was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), appropriate and cooperative, but irritable. She was placed directly in an exam room within the ED. She received report from EMS, which was "short and simple." EMS reported that they were called to the casino because casino security staff felt that Patient #1 had "erratic" behavior. She had refused to answer casino security's questions and EMS staff felt that she was "altered." Upon arrival to the ED, EMS told Staff T that Patient #1 had calmed down for them and felt that she "would be calm for her." Staff T received most of the history from the patient. She asked Patient #1 why she was at the ED. Patient #1 told her that she was not sure why she was there and wanted to go home. Patient #1 reported no past medical history, had not ever been seen at the hospital and had no emergency contacts listed. The triage form included several behavioral health questions, including SI and whether or not the patient had a safe home environment. Patient #1 denied SI and was "very offended when she was asked those questions." Staff T assumed that Patient #1 quit answering questions for the first responders prior to her arrival at the ED because she was irritated with them. Staff T was not present for Staff U's, ED Physician, assessment. After Staff U completed his assessment, they compared notes. Patient #1 knew her home address, reported no complaints and wanted to go home. Staff U said that Patient #1 was appropriate for discharge and that they could not hold her. Staff U completed discharge orders and Staff T provided the discharge instructions to Patient #1. Some patients would be sent home via cab when discharged, if they did not have any family to transport them. That day, due to the inclement weather, the only options for transportation after discharge were patients' family members or the bus system. Patient #1 indicated that she wanted to ride the bus home, her son was working and she did not want to call him. Staff T tried multiple times to get the patient to call her fam