HospitalInspections.org

Based on interview, document review and policy review, the hospital failed to to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care when they failed to enter one patient (#15) on the log of 22 records reviewed from 03/01/25 through 09/08/25. The hospital's average monthly census was 3,818.

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," showed:
- A central log should be maintained of all individuals who came to the ED. An individual came to the ED when the individual presented at the hospital's ED and requested examination or treatment for a medical condition or had such a request made on the individual's behalf.
- An EMC meant a medical condition manifesting itself by acute symptoms of sufficient severity (to include psychiatric [relating to mental illness] disturbances, such as suicidal ideation [SI, thoughts of causing one's own death] or homicidal ideation [HI, thoughts or attempts to cause another's death]) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily function, or serious dysfunction of any bodily organ or part.
- A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether an individual had an EMC or not.
- The MSE should be appropriate to the individual's signs and symptoms. Each individual would receive and have documented in the medical record a MSE that included a behavioral health assessment, as indicated.

Review of the hospital's undated policy titled, "Care of the Suicidal, Homicidal, Unsafe Patient," showed:
- Indications that a patient was suicidal, homicidal, or unsafe may be a report from an ambulance crew, other transporters or observation of patient's verbal and/or action behaviors.
- The staff member who first received information regarding a patient's SI or HI, or concerns for other behavioral health condition, should be responsible for documenting and alerting other staff.
- For ED patients who presented with behavioral health conditions as their primary reason for care they will have a suicidal screening performed on every encounter. Medical stabilizing treatment would be provided as ordered by the ED provider.

Review of the hospital's undated policy titled, "Medical Holds for Psychiatric Patient Safety," showed:
- Medical or nursing staff should designate patients as being on a medical hold status when the patient presented a likelihood of serious harm to themselves or others. A patient on a medical hold was not permitted to leave against medical advice (AMA) and should be required to stay at the hospital which may include direct observation where appropriate and/or requesting assistance from hospital security and safety staff.
- 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 if the patient was in the ED.
- While awaiting behavioral health assessment, nursing staff should monitor the patient and take precautionary steps to ensure the safety of the patient and staff.
- Any medical staff member, Registered Nurse (RN), or other staff member with knowledge that a patient was on a medical hold or temporary medical hold was authorized to detain a patient at the hospital for the patient's safety.

Please refer to A-2405 for further details.

Based on interviews, document review and policy review, the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care when they failed to enter one patient (#15) on the log of 22 records reviewed from 03/01/25 through 09/08/25. The hospital's average monthly census was 3,818.

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," showed a central log should be maintained of all individuals who came to the ED. An individual came to the ED when the individual presented at the hospital's ED and requested examination or treatment for a medical condition or had such a request made on the individual's behalf.

Review of the hospital's undated document titled, "Safety Event Action Plan," showed:
- On 06/18/25 at 4:00 PM, Staff O, Security Sergeant, received a phone call from law enforcement who advised him that Patient #15 needed a mental health evaluation.
- At 4:28 PM, Patient #15 arrived with law enforcement. Law enforcement spoke with staff and were directed to the triage (process of determining the priority of a patient's treatment based on the severity of their condition) area by Staff L, Registered Nurse (RN). While at the triage area the law enforcement officer removed Patient #15's handcuffs and she sat in a chair.
- At 4:38 PM, law enforcement left the hospital. Patient #15 walked to the triage desk. The triage desk was unattended.
- At 4:41 PM, Patient #15 asked a Security Officer (SO) where the restroom was. She then went to the restroom alone.
- At 4:46 PM, Patient #15 exited the hospital at the main entrance.

Review of a written interview on 06/19/25, with Staff R, SO, Staff S, SO and Staff O, Security Sergeant, showed:
- Staff O informed security staff that law enforcement was coming to bring an unnamed patient for a mental health evaluation.
- Staff R met Patient #15 and law enforcement at the triage desk. Law enforcement informed him Patient #15 had a probate warrant (a document that orders the detention or commitment of a person for evaluation or treatment related to mental illness or substance abuse) for mental health.
- A follow up note, after the interview concluded, showed that the law enforcement office was contacted after the event. A fax was successfully sent from law enforcement with the probate warrant at 3:12 PM to the hospital.

Review of a written statement on 06/18/25 at 7:24 PM, Staff L, RN, showed law enforcement presented to the ambulance bay with a female patient in handcuffs. Staff L directed them to triage because there were no open rooms and advised law enforcement to check Patient #15 in there.

Review of the hospital's ED log showed Patient #15 was not listed on 06/18/25.

Although requested a medical record for Patient #15 was not provided.

During an interview on 09/08/25 at 10:19 AM, Staff D, ED Director, stated that Patient #15 should have been put on the ED log. It surprised her that staff had not put Patient #15 on the ED log.

During an interview on 09/08/25 at 11:01 AM, Staff L, RN, stated that law enforcement had called earlier in the day to inform her about the warrant. She provided a fax number to send the court order. She directed Patient #15 to the triage desk when she arrived. She did not put Patient #15 on the ED log but should have done so.

Based on interview, document review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#15) of 22 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," showed:
- An EMC meant a medical condition manifesting itself by acute symptoms of sufficient severity (to include psychiatric [relating to mental illness] disturbances, such as suicidal ideation [SI, thoughts of causing one's own death] or homicidal ideation [HI, thoughts or attempts to cause another's death]) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily function, or serious dysfunction of any bodily organ or part.
- A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether an individual had an EMC or not.
- The MSE should be appropriate to the individual's signs and symptoms. Each individual would receive and have documented in the medical record a MSE that included a behavioral health assessment, as indicated.

Review of the hospital's undated policy titled, "Care of the Suicidal, Homicidal, Unsafe Patient," showed:
- Indications that a patient was suicidal, homicidal, or unsafe may be a report from an ambulance crew, other transporters or observation of patient's verbal and/or action behaviors.
- The staff member who first received information regarding a patient's SI or HI, or concerns for other behavioral health condition, should be responsible for documenting and alerting other staff.
- For ED patients who presented with behavioral health conditions as their primary reason for care they will have a suicidal screening performed on every encounter. Medical stabilizing treatment would be provided as ordered by the ED provider.

Review of the hospital's undated policy titled, "Medical Holds for Psychiatric Patient Safety," showed:
- Medical or nursing staff should designate patients as being on a medical hold status when the patient presented a likelihood of serious harm to themselves or others. A patient on a medical hold was not permitted to leave AMA and should be required to stay at the hospital which may include direct observation where appropriate and/or requesting assistance from hospital security and safety staff.
- 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 if the patient was in the ED.
- While awaiting behavioral health assessment, nursing staff should monitor the patient and take precautionary steps to ensure the safety of the patient and staff.
- Any medical staff member, Registered Nurse (RN), or other staff member with knowledge that a patient was on a medical hold or temporary medical hold was authorized to detain a patient at the hospital for the patient's safety.

Review of a document titled, "Order for 96-Hour (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) Detention, Evaluation and Treatment and Warrant," dated 06/18/25, showed:
- Patient #15 had a history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and previous psychiatric hospitalizations related to SI and HI statements.
- An order, signed by a judge, documented Patient #15 made suicidal and homicidal statements and refused to take her psychiatric medications.
- She needed detention, evaluation, and treatment related to the likelihood that she was at risk of serious harm toward herself or others.
- Her father completed an affidavit (a written statement confirmed by oath, for use as evidence in court) that documented Patient #15 had previously been admitted to a hospital in Kansas where she was recommended to be involuntarily held (a legal process through which a person is hospitalized and treated for mental health disorders without their consent). She was released without family knowledge, refused to take her prescribed medications, made threats to harm herself and believed her children were dead. She was found to have slept in the woods and was homeless without the ability to make safe decisions that her family felt would lead to her death or harm to others if she did not receive help immediately.
- Her daughter completed an affidavit that documented Patient #15 had called her with threats to kill herself and those around her. Patient #15 believed someone had stolen her identity and had used it to get her into trouble, that she was pregnant with twins, and that the government was lying to her about a car. She was living in the woods for a few weeks with a man, despite having a place to live. She had recently stolen her sister's car, threatened several family members for money and had threatened to kill herself. Her daughter found drug paraphernalia in her car after she gave Patient #15 a ride. Her behavior escalated and became more erratic and bizarre.

Review of a police report, dated 06/18/25, showed:
- At 3:53 PM, Patient #15 was arrested on a probate warrant (a document that orders the detention or commitment of a person for evaluation or treatment related to mental illness or substance abuse).
- The responding officer called the hospital to explain the content of the warrant.
- Patient #15 was left with hospital security who advised the responding officer that they would check her into the hospital.

Review of the hospital's undated document titled, "Safety Event Action Plan," showed:
- On 06/18/25 at 4:00 PM, Staff O, Security Sergeant, received a phone call from law enforcement who advised him that Patient #15 needed a mental health evaluation.
- At 4:28 PM, Patient #15 arrived with law enforcement. Law enforcement spoke with staff and were directed to the triage (process of determining the priority of a patient's treatment based on the severity of their condition) area by Staff L, RN. While at the triage area the law enforcement officer removed Patient #15's handcuffs and she sat in a chair.
- At 4:38 PM, law enforcement left the hospital. Patient #15 walked to the triage desk which was unattended.
- At 4:41 PM, Patient #15 asked a Security Officer (SO) where the restroom was. She then went to the restroom alone.
- At 4:46 PM, Patient #15 exited the hospital at the main entrance.

Review of a written interview on 06/19/25, with Staff R, SO, Staff S, SO, and Staff O, Security Sergeant, showed:
- Staff O had informed security staff that law enforcement was coming to bring an unnamed patient for a mental health evaluation.
- Staff R met Patient #15 and law enforcement at the triage desk. Law enforcement informed him Patient #15 had a probate warrant for mental health.
- Staff O believed law enforcement thought they had fulfilled their obligation but did not confirm the hospital had received the court order paperwork.
- A follow up note, after the interview concluded, showed the law enforcement office was contacted after the event. A fax was successfully sent from law enforcement with the probate warrant at 3:12 PM to the hospital.

Review of a written statement on 06/18/25 at 7:24 PM, Staff L, RN, showed law enforcement presented to the ambulance bay with a female patient in handcuffs. Staff L directed them to triage because there were no open rooms and advised law enforcement to check Patient #15 in there. She was later informed Patient #15 had left the building. An hour prior to the incident she received a call from law enforcement, and they informed her that they were going to bring a patient on a probationary matter and asked for a fax number to provide paperwork.

Review of the hospital's undated document titled, "North Kansas City Documents," showed:
- On 06/18/25, an investigation began related to Patient #15's elopement. She had left the hospital prior to the completion of a MSE.
- Root causes for the event included non-receipt of court paperwork from law enforcement, lack of closed loop communication, workflow and process gaps, an unattended triage desk, a full ED, and a need for EMTALA education.
- As a result of the investigation all security and ED staff received education related to EMTALA requirements and process changes. When a patient arrived at the ED with law enforcement security staff were to inquire as to the reason for presentation and escort the individual to the charge nurse desk for supervision. A formal handoff would take place between law enforcement and security staff. The triage desk was to always have staff present.
- Education would be captured by email read receipt and attestations.
- Formal audits were completed by leadership. Security staff would be audited for 100% of individuals accompanied by law enforcement starting on 06/25/25 and continue for four weeks for the reason the individual presented, all other audits would begin on 06/20/25.
- Education attached included the "Care of the Suicidal, Homicidal, Unsafe Patient," "Medical Holds for Psychiatric Patient Safety," "Security Alert - Missing Person," and "Patient Safety Events Including Sentinel Events," policies and EMTALA training.
- Completed attestations showed ED and security staff received education beginning on 06/19/25.

Although requested, a medical record for Patient #15 was not provided.

Although requested, an interview with Staff R, SO, was not provided as he was no longer employed with the hospital.

The law enforcement officer did not respond to several requests for an interview.

During an interview on 09/09/25 at 10:19 AM, Staff D, ED Director, stated that all ED and security staff had received Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) education related to MSE obligations as a result of the event on 06/18/25, when Patient #15 eloped (when a patient makes an intentional, unauthorized departure from a medical facility) before she received a MSE. If there were mental health concerns, she expected security staff to know to watch the patient and not allow them to leave. A patient who arrived with law enforcement for mental health concerns should not have been directed to the triage desk, which should not have been unattended.

During a telephone interview on 09/09/25 at Staff O, Security Sergeant, stated that since Patient #15's elopement security staff had received education that explained what a probate warrant was, and the education had been added to new hire education. He would expect security staff to know that if a patient needed a mental health examination, they could not leave the hospital.

During an interview on 09/09/25 at 11:01 AM, Staff L, RN, stated that she would have expected security staff to have known that patients with SI should not be left alone. Since the event all ED and security staff received education related to EMTALA. A new policy required clinical staff to always be present at the triage desk, and all patients brought in by law enforcement for mental health concerns were brought to the CN desk directly.

During an interview on 09/08/25 at 12:34 PM, Staff H, Security Seargent, stated that if someone was accompanied by law enforcement, they had a checklist to complete, regardless of if they arrived by ambulance or were a voluntary admission. If they arrived with law enforcement, they would stay with the patient until a clinical person was assigned to the patient, and the checklist and handoff were complete. Psychiatric patients who arrived with law enforcement went through triage straight to the CN.

This is cited as previous non-compliance, the hospital identified, corrected and had preventative measures in place prior to the survey entrance.