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Based on interview, review of Emergency Department (ED) logs, medical records, police reports, ambulance reports and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) within its capacity and capability for one patient (#4), and failed to ensure that an EMC was stabilized prior to being discharged for one patient (#17) out of 31 ED sampled cases from 12/13/22 through 06/13/22. The hospital's average monthly census over the past six months was 3,600.

Findings included:

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff," dated 03/26/18, showed that members of the Medical Staff shall comply with Hospital policy Emergency Medical Screening, Treatment, Transfer and On-Call Roster, in accordance with the policy and with federal law, all individuals who come to the Hospital's ED shall receive a MSE by a Qualified Medical Personnel, will be provided stabilizing treatment and, when necessary, an appropriate transfer.

Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," dated 03/30/20, showed that an Emergency Medical Condition (EMC) was either a medical condition manifesting itself by acute symptoms of sufficient severity, including psychiatric (relating to mental illness) disturbances like suicidal ideations (SI, thoughts of causing one's own death) or homicidal ideations (HI, thoughts or attempts to cause another's death) and/or symptoms of substance abuse (misuse of alcohol and/or other drugs), 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 functions or serious dysfunction of any bodily organs or part. The MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual has an EMC or not. Any individual who comes to the ED of this Hospital, shall receive a MSE performed by Qualified Medical Personnel 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. Each individual will receive and have documented in the medical record a MSE which will include a history of the individual's presenting condition, if the individual is unable to provide history, information will be obtained from other sources when available; a physical exam including ongoing observation that is adequate to assess the individual's condition; the use of ancillary services routinely available to the ED, like laboratory, and a behavioral health assessment, as indicated based on the patients history and physical exam; an assessment of suicide or homicide attempt or risk, disorientation, or assaultive behavior that indicates danger to self or others. The individual shall be monitored on an ongoing basis until it is determined whether or not the individual has an EMC, such monitoring shall be reflected in the patient's medical record. Stabilizing treatment is achieved when no material deterioration is likely, within reasonable clinical confidence, to result from or occur during transfer or discharge of the individual. Psychiatric patients are considered stable when they are protected and prevented from injuring or harming themselves or others. The EMC that caused the individual to seek care in the ED is resolved. An individual shall be stabilized prior to discharge, or shall be admitted for inpatient services or appropriately transferred. If an individual indicates refusal to accept all or part of the proposed stabilizing treatment, the responsible physician shall attempt interventions with the individual, including informing the individual of the risks and benefits of the proposed treatment and advising of the risks of refusing the proposed treatment, and the responsible physician shall assess an individual's capacity to understand those risks. If the responsible physician is concerned the individual has a psychiatric disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, the responsible physician should implement the policy medical holds for psychiatric patient safety, and staff may request assistance from security and safety staff. The responsible physician shall document in the individual's chart a description of the treatment that was refused, the patient's capacity to understand the risks, and the attempted interventions.

Review of the hospital's undated policy titled, "Safe Disposition of Patients Under the Influence of Chemical Substances," showed that patients under the influence of chemical substances will be evaluated by the physician for safe disposition when they are alert and oriented, and/or return to baseline neurological (neuro, relating to or affecting the nervous system) status, and return to baseline ambulation status.

Review of the hospital's policy titled, "Medical Holds For Psychiatric Patient Safety," dated 11/12/18, showed that Medical Staff and Nursing Staff shall designate patients as being on Medical Hold status when the patient presents a likelihood of serious harm to themselves or others. Medical Hold Status is an internal patient status designation used where a physician has made a clinical determination that a patient should not be permitted to leave the hospital Against Medical Advice (AMA). The determination of whether a patient is likely to harm themselves or others shall be based on clinical assessment and may be due to a patient's psychiatric disturbance or substance abuse. Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by Behavioral Health Assessment Counselors if the patient is in the ED.

Review of the hospital's undated policy titled, "Plan for Care of Patients Under Legal or Correctional Restrictions," showed that the hospital retains all control of and responsibility for patient care. In no case will patient care be compromised. Care planning must be coordinated between the patient, physician, hospital staff and police to assure all needs are met. The discharge plan and need for continued care will be coordinated between the patient, physician, staff and representatives of the law enforcement agency.

Review of the hospital's undated policy titled, "Care of Suicidal/Homicidal/Unsafe Patient," showed that nursing staff shall follow this policy when providing care for unsafe patients. This included patients with psychiatric complaints, suicidal ideation, homicidal ideation and/or substance abuse problems. The ED staff shall work collaboratively with mental health providers (psychiatry, and/or Behavioral Health Assessment Counselors), to communicate patient needs and changes. Symptoms/disorders which can lead to suicide/homicide include depression (change of eating or sleeping habits, being withdrawn or crying easily), disorientation (experiencing delusions or hallucinations), defiance (wanting complete control of oneself), substance abuse, complex or difficult mental health problems, or mental health related aggression. For ED patients presenting with behavioral health conditions as their primary reason for care, will have a suicide screening performed. Medical stabilizing treatment will be provided as ordered by the ED physician. Patients who screen with low suicide risk will have a mental health referral information given at discharge. Additional patient safety precautions may be considered and initiated per clinical judgement. Patients who screen with medium or high risk will have a Behavioral Health consult. The patient will be placed under direct observation. If a patient requires a medical hold for patient safety, the ED physician should enter an order for medical hold (patient may not leave against medical advice). After assessment by Behavioral Health, the Behavioral Health counselor will collaborate with the ED physician regarding the treatment plan. If appropriate for inpatient psychiatric admission, transfer will be arranged. If outpatient therapy recommended, the patient will be given instructions to include behavioral health follow-up. The plan of care should be documented to include a safe discharge plan.

1. Patient #4, a 36 year old homeless male with an unknown past medical history who presented with psychiatric symptoms to the hospitals ED on three occasions; twice on 01/13/22 and once on 01/14/22. Patient #4 presented to the ED by ambulance on 01/13/22 at 11:36 AM with complaints of vomiting. Documentation showed that Patient #4 would not speak with staff or answer questions, drank from the toilet, forced himself to vomit and then rubbed it across his body. No vital signs or behavioral health examination were performed. No past medical history or home medication list were obtained. He attempted to elope (when a patient makes an intentional, unauthorized departure from a medical facility) but was returned by security. When Patient #4 continued to be uncooperative with staff he was escorted from the hospital by security and his record indicated he left AMA. He returned to the ED four minutes later and stated that he needed his finger looked at and needed psychiatric help. A behavioral health examination was ordered, but the patient would not talk to the behavioral health assessor, so it was not completed. Documentation showed that the physician believed Patient #4 had psychiatric problems but did not feel he needed inpatient treatment. Patient #4 stripped off his clothes, said random things, and refused to answer questions or leave the hospital. He was discharged and escorted from the property by police and given a courtesy ride to a nearby location. Patient #4 presented to the ED by EMS on 01/14/22 at 11:50 AM, for alcohol intoxication. He had been naked outdoors in January exposing himself to others. The physician did not order a behavioral health examination documenting that he had one the previous day, even though the assessment was not completed. Documentation showed that Patient #4 continued to not answer questions, remove his clothing, urinate on the floor, force himself to vomit and eat it. No labs or drug screen were performed to indicate the cause of Patient #4's behavior. No attempt was made to obtain a past medical history or a list of home medications. Patient #4 acted bizarrely, refused to leave the hospital and was escorted out by police. After witnessing Patient #4's behavior right after his discharge, Police called EMS to the parking lot of Hospital A to assess Patient #4 where it was determined that he would be transported to Hospital B. Hospital B admitted him to the behavioral health unit where he was an inpatient from 01/14/22 until 03/17/22. Police, EMS and Hospital B were able to determine that Patient #4 was having a behavioral health emergency after being discharged from Hospital A, based off the same behavior that he exhibited while in the ED at Hospital A. The hospital failed to perform a complete MSE within their capacity and capability to determine that he was having a behavioral health emergency, or stabilize him prior to his discharge. Psychiatrists were on-call and available to staff at the hospital, however Physicians did not call and consult their services.

2. Patient #17 was a 22 year old female who presented to the ED in police custody for altered mental status and combative behavior. The patient thought she was 32 weeks pregnant and had a pillow stuffed under her shirt in the front of her pants. The patient denied being suicidal or homicidal. During her stay in the ED, she was verbally abusive to staff and law enforcement. She was uncooperative in responding to questions and refused to give a urine sample to assess for drugs. The patient was minimally cooperative with the behavioral health assessment and would only answer questions with a yes or no. The patient reported that she had the holy-spirit in her and talked to him. The patient reported she had been hospitalized in the past for psychiatric issues in 2020 and when asked about previous suicide attempts, the patient stated, "Does 2 + 2 = 4?" The patient was not willing to discuss prior suicide attempts any further. The behavioral health assessor determined that the patient was not a harm to herself, but was a harm to others and a safe discharge was into police custody. The patient continued to be loud, inappropriate and she urinated over the bedrails. Lab work showed the patient was not pregnant and the patient was discharged into LE custody with no behavioral health follow-up. LE then transported Patient #17 to Hospital B ED, where she was diagnosed with psychosis and stabilized with medication. Her psychosis and agitation decreased and she was able to give a reasonable discharge plan and discharged from the ED within 24 hours.

Please see A-2406 and A-2407 for additional information.





39562

Based on interview, review of Emergency Department (ED) logs, Medical Records and Policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) within its capacity and capability for one patient (#4) out of 31 ED sampled cases from 12/13/21 through 06/13/22. The hospital's average monthly census over the past six months was 3,600.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," dated 03/30/20, showed that all individuals who come to the Emergency Department (ED) shall receive a MSE by Qualified Medical personnel. An EMC means either a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, impairment, and/or dysfunction of any bodily functions or parts. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual has an EMC. The MSE will include a history of the individual's presenting condition, a physical exam, including ongoing observation, that is adequate to assess the individual's condition, use of ancillary services such as behavioral health assessment, as indicated, and for individuals with psychiatric symptoms, an assessment of suicidal ideation (SI, thoughts of causing one's own death) or homicide (HI, thoughts of attempts to cause another's death) attempt or risk, disorientation, or assaultive behavior that indicates danger to self or others.

Review of the hospital's document titled, "Emergency Call Schedule," dated 01/10/22 through 01/17/22 and 05/01/22 showed that there was a Physician on call for Psychiatry and an alternate physician on call available to ED staff during all three of Patient #4's ED visits.

1. Review of Patient #4's medical record showed that he was a 36-year-old homeless male who arrived to the ED via Emergency Medical Services (EMS, ambulance) on 01/13/22 at 11:36 AM, for vomiting on the side of the street after someone called the police. The police then called EMS who transported the patient to the hospital. At 11:41 AM, Staff L, ED Physician, documented in his assessment, that Patient #4 had initially agreed to go to the hospital to be evaluated, but stopped answering questions en-route to the hospital. The patient stated that he wished to leave and left through the fire exit door into the parking lot. He was escorted back into the ED by security. Patient #4 knew the year, the place, and was able to state his name. He denied being under the influence of drugs or alcohol. Review of systems was unobtainable secondary to the patient's unwillingness to answer any questions. No vital signs, past medical history, home medications, labs or other testing were documented. He did not smell like alcohol and did not appear intoxicated. The neurological (neuro, relating to or affecting the nervous system) evaluation showed Patient #4 was awake and alert, non-focal neurologic exam. He denied SI and did not want to talk about his mental health. Staff O, Registered Nurse (RN), documented at 11:46 AM that Patient #4 asked for something to eat and to use the restroom, when he was escorted to the restroom, Patient #4 began drinking out of the toilet, refused to answer most questions, vomited and then rubbed the vomit across his body. Nursing documentation at 12:00 PM, showed that upon discharge Patient #4 stood up from the bed and spit his food at Staff O. Patient #4 stated that he wanted to be evaluated and he was sick, however he refused to answer questions or have vital signs assessed and staff were not able to get him to engage in conversation. Patient #4 was offered medication for his nausea, but he refused to take it, then began stating his "finger needed to be looked at, he was very sick and realized all of that." When asked why he left, the patient stopped looking at staff and quit communicating. Security was called back into the room to escort Patient #4 out of the ED, and Patient #4 stated that he was still sick and needed to be evaluated. When security stepped away to ask about Patient #4's finger, the patient got up and ran down the hallway. He was returned to his room where he laid on his stomach on the bed, avoided all eye contact and conversation with staff. AMA paperwork was filled out, the section for patient signature stated, Patient refused to sign. He was escorted from the ED and discharged at 12:28 PM. No vital signs, past medical history, home medications, behavioral health examination, labs or other testing were documented. On 01/13/22 at 12:32 PM, Patient #4 presented to the ED for the second time, with a chief complaint of homeless, "I'm hungry." At 12:37 PM, Staff L, ED Physician, documented in his assessment that he had seen Patient #4 in the ED in the last hour. Patient #4 stated that "he would be good this time" and reported two concerns, a red painful finger and he needed psychiatric help. A physical exam showed that Patient #4 was disheveled, repeated "I am hungry, I am hungry, I am hungry" refused to answer any questions, and was not agitated. Staff L requested a mental health assessor see Patient #4, but he refused to talk with them and called her "a psychopath." Staff L documented that he suspected that Patient #4 probably had some underlying psychiatric problems but he did not think that he required inpatient psychiatric treatment at that point and did appear capable of leaving the emergency department under his own power. At 12:37 PM, Staff S, Licensed Clinical Social Worker (LCSW), documented that Patient #4 refused to speak with her, but did acknowledge her when she asked him if he was hungry. Staff S explained to Patient #4 that he had to cooperate before he could have food, but he continued to remain silent. Staff S spoke with Staff L and they decided that Patient #4 would be discharged back to the community. Patient #4 then stripped off all of his clothing, refused to speak and refused to leave the hospital. Police were contacted. At 12:36 PM, Staff O, RN, documented that Patient #4 stated random things, "I'm hungry, I need to be evaluated for my mental health because I am claustrophobic and cannot wear a mask, look at my pinky." When questioned by Staff L, the patient stopped talking and closed his eyes. Patient #4 was told he would not be getting a sack lunch and became upset and demanded to leave. Patient #4 would only repeat that he wanted food and refused to answer any additional questions, and would close his eyes and pretend to sleep. Twice Patient #4 removed all of his clothes and walked around before security would have him redress. It was then decided by Staff L that Patient #4 was stable enough for discharge. Patient #4 was discharged from the ED at 12:50 PM and escorted out by hospital security officers. There were no vital signs, past medical history, home medications, labs or other testing documented as ordered or completed and the behavioral health assessment was not completed. Psychiatrists were on call for ED staff but were not consulted on Patient #4.

Although requested, there was no EMS record of the 01/13/22 at 11:36 AM initial ED visit.

Review of the police document titled, "Offense/Incident Report," dated 01/13/22, at 2:34 PM, showed that at approximately 2:34 PM, Police Officer HH, was dispatched to a city street, in regards to a white male taking off his clothes and stopping traffic. It was noted that another officer had been dispatched to North Kansas City (NKC) Hospital earlier in the day because Patient #4 refused to leave the hospital after he was discharged. He became disorderly and yelled at hospital staff. Patient #4 had to be restrained in order to calm him down. He was then given a courtesy ride to the same location that Police Officer HH responded to. Patient #4 was dressed and inside a gas station upon Police Officer HH's arrival and reported he was there to buy alcohol. Police Officer HH informed Patient #4 that he had been called there because he had been removing his clothing and asked him why he had done that. Patient #4 refused to answer any questions and just stared at him. Police Officer HH observed Patient #4's demeanor to be coherent but lost, showed signs of bipolar (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), schizophrenia (serious mental disorder that affects a person's ability to think, feel and behave clearly) and dissociation (disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity). It was uncertain if Patient #4 was under the influence of narcotics. He was not sure if Patient #4 received a psychiatric evaluation while he was in the hospital.

During an interview on 06/15/22 at 9:00 AM, Staff L, ED Physician, stated that he felt that Patient #4 was not under the influence of drugs or alcohol during his visits on 01/13/22, but had chronic psychiatric issues. Altered mental status could be an indication of a head injury or an infection. Patient #4 was given multiple opportunities to cooperate, but when he didn't he was allowed to leave. Rubbing vomit on himself and drinking from the toilet were obviously strange behaviors, and Patient #4 definitely had some psych issues going on. He still felt that Patient #4 was within his rights to leave. He had no history on Patient #4, or access to past medical history or medications and the patient would not tell him about his past medical history.

During an interview on 06/15/22 at 10:15 AM, Staff O, RN, stated that Patient #4 did not appear to have been under the influence of drugs or alcohol. Potentially it could have been issues with blood work causing the behaviors Patient #4 was having. She did inform Staff L that Patient #4 had drank from the toilet and rubbed vomit on himself, which was why Staff L ordered the Behavioral Health Assessment for Patient #4 on his second ED visit. Patient #4 did not want to leave the hospital, but also did not want to cooperate.

During an interview on 06/15/22 at 11:25 AM, Staff S, LCSW, stated that Patient #4 called her a "psychopath" when she went to do a behavioral health assessment, then completely refused to speak with her. Her behavioral health assessment on Patient #4 was not complete and she did communicate that to Staff L, ED Physician. For patients who were exhibiting the types of things Patient #4 was exhibiting it would be standard to get labs, or even try to place the patient for inpatient treatment.

Review of EMS document titled, "Incident #22-006773," dated 01/14/22, showed that EMS were dispatched to the Grey Hound Bus Station where they found Patient #4 sitting in the floor around clothes and pools of vomit. Documentation showed Patient #4 had signs and symptoms of strange and inexplicable behavior, cognitive functions and awareness were intoxication. Patient #4 refused to answer EMS questions, police were notified, and the patient was placed under custody for being a danger to himself. The police requested for Patient #4 to be evaluated in the ED, so they transported Patient #4 to NKC Hospital.

Review of Patient #4's medical record showed that on 01/14/22 at 11:50 AM, Patient #4 presented to the ED via EMS, for the third time, with a chief complaint of alcohol intoxication and homelessness. At 11:57 AM, Staff P, RN, documented that Patient #4 refused to answer any questions about drug or alcohol use. She noted that he was extremely disheveled and unkempt and did not have any personal clothes or belongings with him. She attempted to get Patient #4 dressed in clean clothes and towels were given to him to clean up. At 12:41 PM, Staff T, ED Physician, documented in her assessment that Patient #4 presented to the ED for being intoxicated and exposing himself to people at the bus stop. Patient #4 had a mental health evaluation on 01/13/22, and he did not want anything. Her plan was to feed him and have a social worker see him to get him clothing and a cab voucher. Home medications included an antibiotic given to him on 01/13/22, with no chronic problems and an unknown procedure/surgical history. At 2:27 PM, Staff Q, Master of Social Work (MSW), documented that Patient #4 was at the bus station taking off his clothing and exposing himself to the population. Patient #4 was resting on the bed, requesting food to eat. Patient #4 would not participate in any conversation other than to report he was hungry. He was given a meal tray and then proceeded to make himself vomit and eat it off the floor/bed. He would not keep his clothing on and refused to speak to most staff. Patient #4 denied SI and HI by shaking his head no, but would not verbalize any other requests or needs. Staff Q documented that there was no indication that Patient #4 needed psychiatric placement at that time due to his behaviors in the ED. At 1:52 PM, Staff P, RN, documented that she informed Staff Q, MSW, that Patient #4 would not get dressed, and continued to vomit all over himself as well as urinate on the floor. Security was asked to get Patient #4 to his cab. Security was unable to get Patient #4 to put on clothes so the police were called. Patient #4 proceeded to eat his own vomit with his hands and urinate on the bed. Staff P documented that if the patient would have cooperated with Staff Q, MSW, he could have had a cab to transport him to a warming shelter. Instead the police were called and Patient #4 was discharged at 2:07 PM.

Review of the Police document titled, "Offense/Incident Report," dated 01/14/22, showed that Police Officer KK, was dispatched to Hospital A at 1:46 PM, regarding a trespasser. Upon his arrival he was told that Patient #4 had been discharged, but refused to leave the hospital. A nurse informed him that Patient #4 was naked and had eaten his own vomit. When Police Officer's entered Patient #4's room he was completely nude and covered in vomit. Police Officers were able to talk him into getting dressed and walking outside by offering him the food he had requested. Once Patient #4 was outside he ate his food and then ran back into the hospital stating that he needed help. Patient #4 was brought back outside by police and sat on the curb. It was decided that Patient #4 was in no shape for jail, and he needed medical/psychiatric help and EMS was called. Patient #4 stuck his fingers down his throat and made himself vomit continuously while stating that he needed help for his mental issues. EMS arrived and placed Patient #4 inside the ambulance, he then decided he did not want to go to the hospital and he was released from the ambulance. Patient #4 was walked to the property line of NKC Hospital by police when he abruptly stopped and took all of his clothes off in public in the 40 degree weather. Patient #4 was then placed on a 96 hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for a mental health evaluation and transported by EMS to Hospital B (acute hospital with psychiatric services). Patient #4 continued to remove his blankets and clothing and bit his finger until it bled and ate items from the garbage can. The Physician at Hospital B appeared to be upset with NKC Hospital staff and stated that Patient #4 should not have been discharged from their care.

Review of the document titled, "Trip Information," dated 01/14/22, showed that at 2:14 PM ambulance crew responded to NKC Hospital in response to a call from Police Officers and found Patient #4 sitting on the curb. Patient #4 had been seen at NKC Hospital for nausea and vomiting, was evaluated and cleared by physicians, the patient was asked to leave and after loitering outside the hospital the police were called. Patient #4 requested to been seen at another hospital. EMS evaluated the patient and he refused care/transportation. EMS released Patient #4, he then stripped off all of his clothes. He was detained by police and handcuffed. Police requested transport to Hospital B for a psychiatric evaluation. Patient #4 admitted to alcohol and drug use. He was uncooperative, but EMS were able to get three sets of vital signs en-route to Hospital B.

Review of Patient #4's medical record from Hospital B, a level four trauma center, dated 01/14/22, showed a past medical history that included schizophrenia and inability to care for himself. Patient #4 did not provide a history so psychiatry and ED notes were obtained. Patient #4 was brought in for bizarre behavior, he was naked, shoved his fingers down his throat and made himself vomit, scooped his vomit up and ate it. Due to those actions he was to be evaluated by psychiatry. A Qualified Mental Health Professional (QMHP), observed Patient #4 responding to internal stimuli (something which causes an action or response) and attempted to eat food from the trash can. Patient #4 was disheveled and not addressing his activities of daily living. He was noted biting his fingers until they were bleeding. Patient #4 would not respond to questions but insisted he was hungry. The psychiatric portion of the medical record showed that Patient #4 had SI and HI, and responded to internal stimuli. Assessment and plan included a diagnosis of schizophrenia and psychosis, a 96 hour hold was put in place per psychiatry, and a consult with psychiatry. Discharge summary dated 03/17/22 showed that early in his hospitalization Patient #4 demonstrated significant disorganization of thought, speech and behavior. He often refused to wear clothes and was unable to meaningfully participate in any significant conversations. He was very clearly unable to care for himself and acute hospitalization was necessary in order to attempt to stabilize him and return him to a status in which he could exist safely outside of a controlled setting of a psychiatric hospital. He was placed on antipsychotic medications and by the time he was discharged his acute psychosis had decreased. He remained clothed and was able to engage in superficial conversations regarding his care and discharge planning.

During an interview on 06/15/22 at 1:50 PM, Staff T, ED Physician, stated that Patient #4 didn't want anything done, he just wanted something to drink and food, so she didn't feel that there was any reason to keep him in the ED. She did not know about his home medications, or his past medical history.

During an interview on 06/15/22 at 10:40 AM, Staff P, RN, stated that Patient #4 was inappropriate in the ED and she was not sure if it was due to him being intoxicated or if it was a behavioral health issue. Patient #4 just wanted to lay down and eat food. Typically she would ask patients about their past medical history and their home medications, but she could not remember if she asked Patient #4 about either of those things.

During an interview on 06/15/22 at 1:30 PM, Staff E, RN, stated that Patient #4 refused most of the resources that were offered to him. She described Patient #4 as behavioral and felt he needed to be seen by a physician and have a behavioral health assessment. Being naked in 40 degree weather was dangerous.

During an interview on 06/15/22 at 10:55 AM, Staff Q, MSW, stated that on 01/14/22 Patient #4 did exhibit bizarre behavior in the ED by eating his vomit and taking off his clothes. This type of bizarre behavior was not uncommon in the ED. She did not think that he had anything going on that would warrant a behavioral health examination. The behavioral health examination that Patient #4 received on 01/13/22 was not complete. He was escorted off the property because he was non complaint and wouldn't get dressed.

During an interview on 06/22/22 at 2:00 PM, Police Officer KK, stated that when he arrived to NKC Hospital, Patient #4 was sitting outside of the hospital on the curb with several hospital security officers present. Patient #4 was vomiting repeatedly and hospital security officers were standing around him yelling at the police to arrest him and just take him to jail. As soon as Police Officer KK saw that Patient #4 was putting his entire hand down his throat and making himself vomit repeatedly he told other police officers that they would not be taking him to jail and called EMS. When EMS responded Patient #4 said he did not want to go to the hospital. At that time there were no affidavits in place to keep Patient #4. EMS released him and as Patient #4 was walking away his pants began to fall down. Police Officer KK told him to pull his pants back up and that was when Patient #4 got completely naked. At that time Police Officers knew he needed to be evaluated for his own safety and protection. Patient #4 could not make good decisions for himself and there was no way he was able to care for himself. Patient #4 needed help. Patient #4 repeatedly told Police Officers and Security Officers that he needed help and that he had mental issues. He was not stable or safe for discharge and there was no way he would be able to go to jail. Patient #4 did not smell like alcohol, and Police Officer KK did not feel that Patient #4 was intoxicated or an alcoholic. Patient #4 seemed like he was "crazy" and he really needed help. Patient #4 being intoxicated with drugs or alcohol never crossed his mind, stating "drunks did not eat their own puke." He was obviously very sick and needed help. Police Officer KK stated that NKC Hospital often did this to patients that were uncooperative, and the hospital staff "just wanted those patients out the door."

During an interview on 06/16/22 at 8:34 AM, Paramedic EE, stated that he responded to the call to pick Patient #4 up from the parking lot of NKC Hospital on 01/14/22. When he arrived Patient #4 was outside sitting on the curb, making himself throw up, and biting his finger making it bleed. He stripped his clothes off and walked down the street. The police detained him because he was naked and it was too cold to be outside naked. Patient #4 absolutely had psychiatric issues going on. He could not determine if Patient #4 was under the influence of drugs and alcohol, or if it was a behavioral health issue, but he definitely needed help. He was naked, making himself throw up, stared at him, bit himself, would not cooperate, but was also not aggressive. Due to his mental capacity, Paramedic EE thought it was strange that Patient #4 had just been released from NKC Hospital.

During an interview on 06/16/22 at 8:55 AM, Staff B, ED Director, stated that Patient #4 was not in the right frame of mind. Psychiatric patients like Patient #4 were difficult to deal with. A complete MSE would typically include labs, and an investigation into the psychosocial wellbeing. He expected staff to keep themselves and the patients safe. No matter how many times a patient presents to the ED, they should receive a complete MSE. A behavioral health assessment or MSE from the previous day was not acceptable. A safe discharge from the ED would be when the patient was safe at home, safe follow up and a safe environment where patients were not putting themselves into further harm.

During an interview on 06/16/22 at 9:30 AM, Staff FF, ED Medical Director, stated that a thorough MSE for a psychiatric patient would include a psychiatric screening examination.

The hospital failed to provide Patient #4 with an adequate MSE, to include a thorough behavioral health screening to rule out an EMC. Patient #4 was minimally cooperative with the BHA. There were no ancillary testing ordered or obtained for Patient #4 to determine the cause of his behavior. Due to the lack of details obtained from the patient, the hospital did not have enough information to determine if he had an EMC and could be safely discharged into Law Enforcement (LE) custody and later into the community after release from LE.







39562

Based on interview, record review and policy review, the hospital failed to ensure an emergency medical condition (EMC) was stabilized when one patient (#17) out of 31 sampled cases from 12/13/21 through 06/13/22 was discharged from the Emergency Department (ED). The hospital's average monthly ED census over the past six months was 3,600.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," dated 03/30/20, showed that all individuals who come to the ED shall receive a Medical Screening Exam (MSE) by Qualified Medical personnel. An EMC means either a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, impairment, and/or dysfunction of any bodily functions or parts. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual has an EMC. The MSE will include a history of the individual's presenting condition, a physical exam, including ongoing observation, that is adequate to assess the individual's condition, use of ancillary services such as behavioral health assessment, as indicated, and for individuals with psychiatric symptoms, an assessment of suicide or homicide attempt or risk, disorientation, or assaultive behavior that indicates danger to self or others. The individual shall be monitored on an ongoing basis until it is determined whether or not the individual has an EMC, and if such condition exists, until the patient is stabilized. Stabilization is achieved when no material deterioration is likely, within reasonable clinical confidence, to result from discharge of the individual. Psychiatric patients are considered stable when they are protected and prevented from injuring or harming themselves or others. The EMC that caused the individual to seek care in the ED is resolved.

2. During an interview on 06/16/22 at 9:30 AM, Staff FF, ED Medical Director, stated that the hospital's capabilities included Psychiatrists who are on call 24 hours a day, seven days a week for the ED.

3. Review of the pre-hospital Emergency Medical Systems (EMS, ambulance) document titled, "Dispatch ID 22-0827," dated 05/01/22, showed that Patient #17's primary symptom and impression was altered mental status. Law enforcement requested transport of Patient #17 to the hospital due to erratic behavior. When EMS arrived on scene at 10:59 AM at a local gas station, the patient was found on the ground in handcuffs. She was agitated and combative with police. It was reported to EMS staff from the police sergeant, the patient was yelling at customers at the gas station and became combative with them; the patient was saying things that did not make sense. EMS staff attempted to talk with the patient and she became verbally abusive and uncooperative. She would not answer questions and kept requesting a stuffed pillow be put down her pants. The patient's heart rate was high, at 139 to 156 beats per minute and her blood pressure (BP) was elevated at 134/97 to 168/108.

4. Review of Patient #17's NKC Hospital medical record showed that she was a 22 year old female that was brought to the ED by ambulance in police custody on 05/01/22 at 11:20 AM. The reason for admission to the ED was altered mental status (AMS) and because she was combative. Her chief complaint was she was 32 weeks and four days pregnant. She was talking about people following her from Arizona. She had been aggressive by report from nursing staff and police. She was in handcuffs and shackles. She had an altercation prior to coming to the ED and the police were present with the patient. The patient denied being suicidal or homicidal. At 11:43 AM, Nursing documentation showed that Patient #17 was being loud, inappropriate and rude. She refused to answer questions. The physician's review of systems showed psychiatric as no anxiety, no depression, normal mood and affect. Her thought process was "clear and linear." The patient's gastrointestinal physical exam showed soft, non-tender, non-distended, no palpable masses, no rebound or guarding, there were absolutely no signs of pregnancy and especially not 32 weeks and four days. The patient was alert and oriented to person, place and time. Her Glasgow Coma Scale (GCS, based on eye, verbal and motor response in which 15 indicates a fully awake patient) was 15. She had normal mentation and speech. Blood labwork drawn showed the patient was not pregnant. At 11:46 AM, the patient's vital signs remained elevated, with a BP of 150/82 and a heart rate of 130 (normal BP range was 90/60 to 120/80 and normal heart rate range was 60 to 100). No other vital signs were documented.

At 12:42 PM, Staff D, Behavioral Health Assessor performed a behavioral health assessment and documented the patient was in police custody after assaulting an officer, was minimally cooperative, and would mostly only answer questions with a yes or no. The patient denied SI, HI and audio/visual hallucinations (AVH). The patient reported that she did have the Holy Spirit in her, so she talked to him as if she was talking to someone else. The patient reported that she had been psychiatrically hospitalized in the past, possibly in 2020, and when asked about previous suicide attempts the patient stated, "Does 2 + 2 = 4?" The patient was not willing to discuss the prior suicide attempt any further. The patient denied alcohol use and stated that she was 32 weeks pregnant and would not do that to her child. The patient struggled with anxiety, depression and undiagnosed post-traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock) due to abuse as a child. Staff D documented that the patient was a danger to others, but was currently in police custody, which was appropriate. No immediate behavioral health needs were needed and no current justification for admission.

At 1:12 PM (after the BHA was completed), the patient was belligerent and calling people, "[expletive] and [expletive]." Staff M, RN, went into the room to help the patient go to the restroom. The patient grabbed the police officer. The patient put her legs through the bed and urinated all over the bed and the floor. At 1:18 PM, Staff U, ED physician, entered an order for patient discharge. At 1:36 PM, the ED staff discharged patient # 17 to police custody. The medical record did not contain evidence Staff U, ED physician, re-examined/re-evaluated the patient prior to discharge. The discharge instructions showed the patient did not have a condition that needed to be treated in the ED. The patient could safely wait until they could be seen by their healthcare provider for evaluation or treatment. It was up to the patient to make an appointment for follow-up care.

5. Review of the law enforcement document titled, "Offense/Incident Report - Complaint 22-0884," dated 05/01/22, showed that law enforcement (LE) were dispatched on a reported party refusing to leave a local gas station property. Documentation showed, upon arrival at approximately 10:37 AM, Patient #17 appeared to be experiencing an altered mental status. The patient stated she was pregnant and had a stuffed animal pillow under her shirt, tucked into the front of her pants. The gas station attendant reported the patient came into the store cursing and bothering staff and customers. She was asked to leave and she remained in the parking lot, yelling at customers as they entered and exited the store. The patient became defiant, verbally abusive and uncooperative with LE. She was transported by EMS to North Kansas City (NKC) Hospital. Further documentation showed, at the hospital she began yelling, cursing, berating staff, talking to herself, laughing, crying, and accused hospital staff and officers of various crimes. The patient displayed a roller coaster of emotions during the entire evaluation/treatment process, ranging from happy, rage, crying, prayer, threats, spitting, etc. Psychiatric questions were asked, however hospital staff did not consider her a threat to herself or others despite her mental status. While waiting on blood work results, Patient #17 wished to provide a urine sample. As noted in the LE document, the officers began to remove the patient's hands from handcuffs and the patient again started to become combative. The nurse then wished for the patient to remain in bed and a bedpan would be provided. The patient refused to use a bedpan, positioned her legs over the bedrails and urinated in the bed and on the floor. Hospital staff then stated her test results were complete, she was medically cleared and required no medical treatment or further psychiatric evaluation. A short time later she was discharged. The patient was brought to a local county sheriff's detention center for housing, deputies refused to take her into custody, citing she was not medically cleared for confinement due to the patient continued to be abusive, uncooperative and non-compliant. The patient was then transported to Hospital B for evaluation.

6. During an interview on 06/17/22 at 10:30 AM, Paramedic JJ, stated that he was the paramedic that transported Patient #17 to NKC Hospital. When he arrived on the scene, the patient was yelling profanities at police that were present. She was not making any sense; she was upset that the police had removed a dog pillow that was stuffed in the front of her pants. The patient believed she was having a baby named William and was responding to internal stimuli from this unborn child. Due to responding to internal stimuli and aggressive behavior towards police, gave enough grounds to transport the patient to NKC Hospital. He tried to deescalate the patient but she continued to be verbally abusive. He suspected she was having a mental health crisis from the way she was acting.

7. During an interview on 06/20/22 at 1:00 PM, Police Officer II, stated she recalled Patient #17 and was part of the initial contact with the patient at the gas station. She remembered the patient was rambling, talking a mile a minute. She definitely had an altered mental status. She wanted to be in a safe place, but didn't think she was in a safe place, but also didn't want to leave when asked to leave. She had an animal pillow stuffed in the front of her pants; she said she was pregnant. She rode in the ambulance with the patient and stayed with her during her treatment at NKC Hospital. She continued to have vulgar language, defiant and wanted to be in control. The patient was mentally unstable, either from drugs or mental health issues. The patient would be laughing, crying and screaming within seconds of each other. The physician assessed her and asked if she was suicidal and she responded yes. The social worker came in and talked with the patient and reiterated the same questions as the doctor asked, the patient was not cooperative with the questioning and the social worker didn't probe the patient for more indepth answers.

8. During an interview on 05/15/22 at 9:30 AM, Staff M, RN, stated that she remembered Patient #17. She was assigned to care for her during the 05/01/22 ED encounter. The police picked her up at a gas station for an altercation with a police officer and altered mental status. She was brought in by ambulance in police custody and shackled. She kept saying she was pregnant; she stuffed clothes inside her shirt to portray a baby bump. She wouldn't let anyone touch her. She was very rude and combative and then she would be nice and the next minute she would be sexually inappropriate. She was going to ambulate the patient to the bathroom, the patient grabbed at the police officer. She was reshackled to the bed and stated, "Yeah bitch, take them off and I will show you what I can do." Staff M, went to get a bedpan and the patient took her underwear off, put her legs through the bedrails and urinated on the bed and the floor. The patient did that twice. All behavioral health patients were on close observation until the patient was discharged or the behavioral health assessor informed staff that the patient was not a threat to themselves or others. The patient was safe to be discharged to police custody. She was not a danger to herself. She was alert and oriented to person, place and time. She denied SI and HI. She was verbally inappropriate to staff, she was not screaming or trying to run. She was her own person. She refused to have vital signs taken. No medications were ordered for the patient. If a patient was combative and noncompliant, the physician would order Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) to be administered.

9. During an interview on 05/15/22 at 1:45 PM, Staff U, Physician stated that he remembered Patient #17. She came into the ED by police and was not happy to be there. She claimed to be 32 weeks pregnant. She was not too aggressive or he would have given her Haldol. She was able to be deescalated verbally. She claimed to have a psychiatric history. She denied being suicidal or homicidal. She could very well have had psychosis or wanted to get away from police custody by saying she was pregnant. A lot of people talk to God, that didn't mean they were psychotic. The patient was able to tell him who she was and answered questions appropriately. He had a hard time taking a patient's rights away and holding them involuntarily. There were many people with psychosis that are able to function in this world. Patient #17 probably had some degree of psychosis but was safe to be discharged. The police were not able to stabilize and provide medical care while the patient was in jail. The patient was expected to follow up with primary care physicians (PCP) after release from jail. The patient was given the phone number of a PCP to contact after she was released. A patient would not be safe for discharge if they could not participate in conversation and struggled with all reality.

10. During an interview on 05/15/22 at 2:30 PM, Staff D, Behavioral Health Assessor, stated she remembered Patient #17. She came into the ED in police custody after assaulting a police officer at a gas station. She had been sleeping in her car at the gas station. She was escorted by two police officers. The patient said she was pregnant and the physician confirmed that she was not pregnant. It was difficult to tell if the patient was making up the story of being pregnant to get out of going to jail or if she was delusional. The pregnancy seemed real to the patient. The pregnancy was a protective factor for her; she denied SI, HI and drug use because she did not want to harm her baby. She did not want to die or hurt herself because of her baby. The patient said she would hear the voice of God and talked to him like talking to someone else. The patient was not responding to internal stimuli when she assessed her. The patient denied thoughts of hurting anyone else, but verbally attacked staff. The patient was safe to be discharged to police custody because she was alert and oriented and understood her situation. She was not a danger to herself. The police had the capability to do a suicide watch if the patient needed that. She remembered talking to the physician after assessing the patient and gave her recommendation. The patient would not have been discharged if not going to be in police custody. The first choice for discharge would have been a local assessment and triage center (ATC, a safe place where persons with mental health and substance use disorders could be assessed and stabilized. If needed, they would then be referred to behavioral health outpatient or residential services for treatment. Clients were able to stabilize for up to 23 hours in an observation room where they engaged with a licensed social worker and case manager to determine a successful discharge plan) The patient would have been cabbed to the ATC. If the patient was not agreeable to go to the ATC, she would have been a candidate for an involuntary hold for inpatient behavioral health admission because of her delusional pregnancy and minimal cooperation with the BHA. All discharge plans were collaborated with the ED physician.

11. During an interview on 06/20/22 at 1:15 PM, Police Officer HH, stated that he transported the patient after discharge from NKC Hospital to a nearby county detention center for arrest. The staff at the county detention center would not accept her due to the patient being in an altered manic state. She was irate, disrespectful, and aggressive with detention officers when trying to assess vital signs. The patient would answer questions with another question. The nearby county detention center said she was not fit for confinement. Police Officer HH then transported the patient to Hospital B and the patient continued to be irate and uncooperative with hospital staff. At hospital B they were met by security and escorted back to the area of the ED where psychiatric patients were assessed. She continued to yell obscenities, made threats that God was going to make them pay for what they were doing to her. Within in 30 minutes of entering Hospital B, the hospital staff knew she was not mentally culpable and needed to be admitted for her mental issues.

12. Review of Patient #17's Hospital B Medical Record showed that she arrived to Hospital B ED on 05/01/22 at 2:49 PM for a psychiatric evaluation. She was brought in by LE after being seen at NKC hospital for evaluation of pregnancy and abdominal pain. The patient was not pregnant, but still insisted that she was. She repeatedly said other nonsensical things and would not cooperate with any history or evaluation. A qualified mental health professional (QMHP) assessed the patient on 05/01/22 at 8:54 PM. The patient appeared to be experiencing auditory and visual hallucinations as evidenced by her looking towards the wall and asking, "What is it?" while nodding her head in agreement before resuming the interview with the QMHP. The patient also appeared delusional as evidenced by thinking that people were after her from across the country as well as thinking she was pregnant despite NKC hospital's evaluation proving otherwise. The patient was hyper-verbal, profane and uncooperative. Her speech was rambling, pressured and rapid. Her behavior was aggressive, explosive, hostile, impulsive, inappropriate and paranoid. The patient's level of risk was unclear at this time due to her psychotic presentation and her uncooperative behavior. The patient's bizarre behavior presented some risk of danger but patient denied SI and HI. The QMHP's impression was unspecified psychosis. The patient's bizarre and psychotic behavior may put the patient in dangerous situations due to her inability to care for herself. The QMHP recommended either a psychiatric consult for further evaluation or discharge if the patient's presentation improved in the ED. A Psychiatric Consult Evaluation was completed on 05/02/22 at 2:16 PM. The patient reported she was 32 weeks pregnant with twins, named William and other, and whose head had been compressing her pubic bone since last Thursday. The patient exhibited disorganized thought and speech. The patient was given two doses of Droperidol (an antipsychotic medication) intramuscularly (IM, in the muscle) with notable improvement in agitation and linearity of thinking.

13. The hospital failed to stabilize Patient #17 prior to discharge into LE custody. Patient #17 was minimally cooperative with the BHA and refused to provide a urine sample for a drug screen. Patient #17 was not stabilized and continued to show signs of psychosis and erratic behavior. Patient #17 was given a name and phone number of a PCP and did not include behavioral health follow-up or resources. The hospital's capabilities included on-call psychiatrists available to the ED 24/7. The evidence in the medical record showed the on-call psychiatrist did not evaluate the patient prior to ED staff discharging patient # 17 from the ED. The ED physician documented the patient had a normal mood and affect with clear and linear thoughts. In contrast, documentation by the BHA showed the patient had a history of significant mental health problems, displayed aggressive, erratic and inappropriate behavior prior to coming to the ED and while in the ED, and falsely believed she was 32 weeks pregnant. Further documentation by the BHA showed the patient was a danger to others. At 1:36 PM, the ED staff discharged Patient # 17 to police prior to stabilizing the patient's psychiatric emergency medical condition. At 2:49 PM, approximately an hour after discharge, police brought the patient to a second hospital ED where she received treatment to stabilize her psychiatric emergency medical condition.















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