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Based on interview, document review and policy review the hospital failed to ensure emergency medical treatment and labor act (EMTALA) requirements were met by failing to ensure a central log was completed for each patient presenting to the emergency department; by failing to provide an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether an emergency medical condition (EMC) existed; by failing to provide necessary stabilizing treatment; and by failing to ensure a patient was transferred by qualified personnel and transportation.

The cumulative effect of these deficient practices has the potential for all patients to be discharged/leave with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including death.


Findings Include:


1. Review of the Hospital's policy titled, "EMTALA - Compliance with the Emergency Medical Treatment and Labor Act," dated 03/2013, showed the ED shall maintain a log of all persons seeking care.

Review of the policy titled "EMTALA [Emergency Medical Treatment and Labor Act]," revised April 2021, indicated ". . . VI. Documentation Requirements. . . B. The Emergency Department shall maintain a log of all Covered Persons, with the exception of pregnant women examined in the Labor & [and] Delivery Department; that department shall maintain a log of such persons. Each entry in the Emergency Department log and the Labor & Delivery Department log shall include the name of the Covered Person and the disposition, i.e. [that is], whether the person: (1) refused treatment, (2) was refused treatment by the facility, (3) was transferred, (4) was admitted and treated, (5) was Stabilized and transferred, or (6) was discharged. . ."

Patient 12's visit on 11/11/20 was not documented on the ED log. Patient 11's visit on 04/21/21, an obstetric (OB) patient, was not documented on the ED log. The OB ED log showed 19 patients listed did not have documentation of the patients' disposition and 60 patients listed did not have documentation of the time the patient left the unit.
Patient 24's visit failed to be entered on the log upon arrival to Facility B (remote ED location of Hospital A). Refer to 2405


2. Review of the policy titled, "EMTALA - Compliance with the Emergency Medical Treatment and Labor Act," dated 03/2013, showed the facility shall provide each person an MSE beyond initial triage. The decision whether a person has an EMC shall be made by a qualified medical professional (QMP) who personally examines the person. The scope and extent of an MSE shall be appropriate to the person's condition, including symptoms and history. If a person refuses to be examined and/or treated in the ED, the employee who interacts with the person shall properly document such refusal on a "Leaving Hospital Against Medical Advice Form." The ED shall generate a medical record for each registered person. The ED shall maintain a log of all persons seeking care.

Review of the policy titled, "EMTALA [Emergency Medical Treatment and Labor Act]," revised April 2021, indicated ". . . Emergency Medical Condition or EMC means: A. any condition that is a danger to the health and safety of the patient (or, with respect to a pregnant woman, the health of the woman or her unborn child) if not treated in the foreseeable future . . .[Hospital A] shall provide each Covered Person an MSE beyond initial triage. . . the decision whether a Covered Person has an EMC shall be made by QMP [qualified medical personnel] who personally examine the Covered Person. . ."

The hospital failed to ensure each individual who came to the emergency department (ED) had an appropriate medical screening examination (MSE) for three patients (Patients 12 and 24) of 24 ED records reviewed. Refer to 2406.

3. Review of the policy titled, "Scope of Services for Emergency Care: Off-Campus Site," dated 03/2017, showed the "department is responsible for immediate treatment of any medical emergency, for initiating lifesaving procedures in all types of emergency situations, and for providing emergency care for other conditions including chronic and minor illnesses or injury in accordance with EMTALA."

The hospital failed to ensure each patient who came to the emergency department (ED) had treatment to stabilize their emergency medical condition (EMC) for two patients (Patients 8 and 12) of four ED records reviewed for stabilizing treatment prior to transfer from a sample of 24 patients. Refer to 2407


4. Review of the policy titled, "EMTALA," revised April 2021, indicated ". . . VII. Patient Transfers. . . I. To effectuate the transfer, nursing staff shall, with the assistance of the QMP, complete the following tasks and document their completion in the Covered Person's medical record: . . . 2. Arrange for qualified personnel and transportation equipment as required to effect the transfer safely, including the use of necessary and medically appropriate life support measures during the transfer."

Review of the policy titled, "Mental Health Screening/Suicide Precautions," revised February 2021, showed the purpose was to "identify patients who are in need of mental health screening, ... obtain mental health screening, diagnosis, and recommendation for appropriate level of care, ... identify patients whose behavior may be detrimental to themselves or others, ... with respect to patients at risk of harm to themselves or others, to: provide the appropriate level of observation ... provide nursing and environmental measures to promote security and safety for patients with self-harm impulses . . . Mental Health Services shall coordinate with and assist the QMP [qualified medical personnel] with arrangements for follow up treatment, transfer, and safe transport, if needed. Any transfer shall be conducted in accordance with the EMTALA [Emergency Medical Treatment and Labor Act] Policies and procedures."

The hospital failed to ensure patients (Patient 4 and Patient 12) were transferred by qualified personnel. Patient 4 was experiencing suicidal ideation and transported in a car accompanied by family. Patient 12 had an emergency medical condition that was not stabilized prior to transfer from the Intensive Care Unit (ICU) to a psychiatric hospital and was transported in a police car accompanied by a police officer. Refer to 2409

Based on policy review, record reviews, and interviews, the hospital failed to ensure a central log was maintained for each individual who presented to the emergency department (ED) seeking assistance.
1. Patient 12's ED visit on 11/11/20 was not documented on the ED log when he presented to the ED and was transferred from Facility B (off-site ED of main hospital campus) to Hospital A (main hospital.)
2. The OB ED log, reviewed from 11/01/20 to 08/24/21, indicated 19 patients listed did not have documentation of the patients' disposition and 60 patients listed did not have documentation of the time the patient left the unit.
3. Review of the document titled, "Central Log," dated 08/01/21 to 10/04/21 showed Patient 24 failed to be entered on the log upon arrival to Facility B on 09/25/21 at 12:46 PM.

These failures had the potential to affect all patients presenting to the ED and the OB unit.

Findings Include:

1. Review of Facility B's ED log failed to show Patient 12 listed on the log on 11/11/20.

Review of Patient 12's "Transfer of Care To Main Campus Certification Form," presented by Assistant Vice-President of Quality (AVPQ) and not located under a tab in the electronic medical record (EMR), showed Patient 12 was transferred from ED B to Hospital A's intensive care unit (ICU) on 11/11/20 at 3:44 PM.

During a telephone interview on 08/25/21 at 10:10 AM, NP 1 stated that the sheriff's department stated Hospital E (a psychiatric hospital) wanted Patient 12 more medically stable before they would accept the patient. NP 1 stated she asked the sheriff's department and EMS to give her time to contact the hospital admitting provider to arrange a direct admit. NP 1 stated while trying to arrange the direct admit, it was decided by the sheriff deputy to transport Patient 12 to the ED. NP 1 stated EMS "kept the patient the entire time." NP 1 stated he/she didn't remember if EMS brought Patient 12 into the ED or if Patient 12 remained in the ambulance. NP 1 stated the transfer form was handed to the sheriff's officer, and they transported Patient 12 to Hospital A. NP 1 stated Patient 12 was not registered on the ED log, because Patient 12 was already accepted as a direct admit to Hospital A.

2. Review of the OB ED log, presented by AVPQ and reviewed from 11/01/20 to 08/24/21, showed 19 patients listed did not have documentation of the patients' disposition, and 60 patients listed did not have documentation of the time the patient left the unit.

During an interview on 08/25/21 at 11:50 AM, RN 5 stated the OB log should be complete with a disposition and a time the patient left the OB department.

3. Review of the document titled, "Central Log," dated 08/01/21 to 10/04/21 showed Patient 24 failed to be entered on the log upon arrival to the hospital on 09/25/21 at 12:46 PM.

Review of video footage from 09/25/21 at 12:46 PM showed Patient 24 arriving at the ED and presenting to the registration desk. The patient was in the waiting room from 12:46 PM to 12:51 PM (five minutes) before getting up and exiting to the waiting room hallway, out of view of the camera. The patient then is seen exiting the ED at 12:51:55 PM.

During an interview/phone call on 10/04/21 at 10:45 AM, Patient 24, stated that she fell in the early morning of 9/25/21 over a child safety gait, landed on her stomach and her left side. "I really felt ok, but I was just worried there might be something wrong. I called my mother and she said I should be seen." She stated that she went to the ED somewhere between 10:30 AM and 11:00 AM, but she cannot recall the exact time. Upon arrival she told the female (unknown name) setting behind the window her name, other information and the reason she was seeking services. She stated that she was told to take a seat in the waiting area. After a few minutes a male (unknown name) came to her in the waiting room and told her "unfortunately we do not have the fetal monitoring equipment to check on the baby." He then asked her where her primary care physician was. Patient 24 stated that he replied to her options would be to go to another facility to be seen. He suggested she go where you are already established by a Primary Care Physician (PCP). Patient 24 stated that she was not taken back to an exam room, received any form of medical exam and or did not sign any documents at the ED, before exiting the ED.

Request for review of Patient 24's discharged medical record showed the hospital had no documentation concerning her ED visit on 09/25/21.

During an interview on 10/04/21 at 1:15 PM, Staff C, ED Director, stated that when a patient arrives at the registration desk and request to be seen by ED staff, the registration staff uses a two-computer system to register patients. The patient's information is first entered into MedHost computer program. The information is then entered into the Computer Programs and Systems Inc (CPSI) program. Entering the patient's information into MedHost, allows for a patient to be recorded on the ED log. Staff C stated that patients may not show up on the ED log for reasons that include computer outage, Information Technology (IT) issues, or the two computer systems are not merging together. Staff C stated that the registration staff is knowledgeable of how to manually put in patient information so that it appears on the ED log. Stated that it is rare to have computer issues of the two systems being down or patients not being placed on the ED log.

During an interview on 10/04/21 at 5:00 PM, Staff B, Chief Nursing Officer (CNO), stated that she was made she could identify at 12:00 PM on 10/04/21 a name of a patient that was not entered onto the ED log on 09/25/21. Staff B stated that on that day, the facility was having issues with the two computer systems merging information, the patient did show up on an audit of CPSI, but not in Med host, where the information is documented on the ED log. Stated that the encounter could have been deleted.

Review of the hospital's document titled, "Audit Log," dated 10/04/21, showed that Patient 24 did present to the ED. Registration staff did enter Patient 24's information into the system on 09/25/21 at 12:48:57 PM.

During an interview on 10/05/21 at 8:33 AM, Staff D, ED Advanced Registered Nurse Practitioner (ARNP), stated that he did speak with Patient 24 in the ED on 09/25/21. He stated that Patient 24 relayed to him, that she had fallen earlier in the day, and she informed registration staff that she was wanting a fetal sonogram (a computerized picture of items in the body). Staff D stated that he informed Patient 24 that the facility did not have that type of procedure available at the Off-Campus ED, and suggested she be seen by her PCP or another facility. He did not know if the patient was registered on the ED log, doesn't recall seeing a face sheet for Patient 24, and recalls that the facility was having problems with the computer system that weekend. Staff D stated that he was contacted by Staff B, CNO, sometime last week about a possible EMTALA violation, and if he could recall the patient's name, since they could not find the patient on the ED log. Staff D stated that he was contacted the previous day by Staff E, Chief Executive Officer (CEO) regarding his contact with Patient 24.

During an interview/phone call on 10/05/21 at 9:43 AM, Staff F, ED Registered Nurse (RN), stated that the ED log is completed by the Registration Department. She stated that on 09/25/21, she believed the facility was having computer issues. She does not recall if any patients were turned away, chose to seek care somewhere else, or were not placed on the ED log.

During an interview/phone call on 10/05/21 at 10:10 AM, Staff G, Business Office Director, stated that when a patient presents to the ED, they express desire to be seen to the registration desk. The registration personnel ask for the patient's name, date of birth, PCP, and reason for visit. They provide the patient with the Bill of Rights, consent to be treated, and then create account in MedHost. Once the account has been created in MedHost, the patient will show up on the ED log. Staff G stated that she deletes patient accounts if the patient request that they be, registration staff does not have access to delete accounts. She is unaware of any recent requests by patients to have their account deleted.

During an interview/phone call on 10/05/21 at 10:30 AM, Staff H, Registration Receptionist, stated that when patients arrive in the ED, she asks them why they are requesting to be seen, their name, date of birth, she signs into the system, and makes a profile for the patient. They sign the consent for treatment, and placed into MedHost. If there is a problem with the patient not showing up in MedHost, she calls the IT department. States that IT problems are rare. Once the patient shows up in MedHost, they are immediately placed on the ED log. There is no paper log that is maintained. Staff H stated that a couple weeks prior, a female came into the ED via the registration desk, and asked to be seen. The patient stated she fell at home, was 35 weeks pregnant, was concerned about the well-being of the baby, and wanted to be seen. The patient was checked in as a fall injury. Staff H stated she called back to the ED nurse's station to notify staff of arrival. She stated that Staff D, ARNP, came out to see the patient in the waiting room hallway. She stated that Staff D had informed Patient 24 that the ED could see her, but did not have ultrasound capabilities and that she should follow up with her PCP or go to another facility. Staff H stated that she deletes patient accounts when they leave without being seen, or emails those accounts to Staff G, Business Office Director, for her to delete the encounter for the patient.

During an interview on 10/04/21 at 12:37 PM, Staff B, CNO, stated that she was notified of a possible EMTALA violation on 09/28/21. The violation involved a female, 35 weeks pregnant, who was seen at another facility. She stated that her receptionist initially took the call, and then passed it on to her. She then passed the information on to Staff C, ED Director, and to Staff F, ED RN. Staff B stated that she has interviewed Staff F, Staff H, and Staff D. She contacted Staff G, on 09/29/21, and asked if the patient could be located on the ED log. Staff D was emailed a second time, on 10/04/21 to verify the patient. Patient 24 was not located on the ED log. Staff B states she has not self-reported to CMS, KDHE, or to the Director of Risk Management at the facility.

Based on policy review, patient medical record review, and interviews, the hospital failed to ensure each individual who came to the emergency department (ED) had an appropriate medical screening examination (MSE) for two patients (Patients 12, and 24) of 24 ED records reviewed. This failure had the potential to affect any patient who presented to the ED and required an MSE.

Findings Include:

1. Review of the 11/11/20 EMS trip report indicated EMS was summoned to Labette's off-campus ED in Independence, KS at 3:40 PM to transport Patient 12 to the hospital's main campus ICU.

There was no documentation to show Patient 12 presented to the off-campus ED or that a medical screening exam (MSE) was completed by Nurse Practitioner (NP) 1 who was working in the off-campus ED when Patient 12 arrived.

Review of Patient 12's "Transfer of Care To Main Campus Certification Form," presented by Assistant Vice-President of Quality (AVPQ) and not located in the electronic medical record (EMR), showed Patient 12 was transferred from the off-campus ED to the main campus intensive care unit (ICU) on 11/11/20 at 3:44 PM. There was no documentation in the EMR of a MSE completed by Nurse Practitioner (NP) 1 who was working in the off-campus ED.

During a telephone interview on 08/25/21 at 10:10 AM, NP 1 stated it "was more of a transport, because [Patient 12] was being admitted from the county jail." NP 1 stated a call was received from the sheriff's department and EMS (emergency medical services) who stated Patient 12 had been evaluated previously by a mental health provider, and at the time there was not a bed available at Hospital E (a psychiatric hospital). NP 1 stated the sheriff's department stated Hospital E wanted Patient 12 more medically stable before they would accept him. NP 1 stated he/she asked the sheriff's department and EMS to give NP 1 a moment to contact the admitting provider to arrange a direct admit. NP 1 stated while NP 1 was trying to arrange the direct admit, it was decided by the sheriff deputy to transport Patient 12 to the ED. NP 1 stated EMS "kept the patient the entire time." NP 1 stated NP 1 didn't remember if EMS brought Patient 12 into the ED or if Patient 12 remained in the ambulance. NP 1 stated he/she remembered NP 1 handed the transfer form to the sheriff's officer, and they transported Patient 12 to the main campus. NP 1 stated he/she did not perform a MSE for Patient 12 on 11/11/20 before Patient 12 was transported to the main campus ICU.

2. Review of video footage on 10/04/21 at 1:50 PM, showed at 12:46 PM, on 09/25/21, Patient 24 arrived at the ED, and the patient presented to the registration desk. The patient was in the waiting room from 12:46 PM to 12:51 PM (five minutes) before getting up and exiting to the waiting room hallway, out of view of the camera. The patient then is seen exiting the ED at 12:51:55 PM. The hospital staff failed to document an MSE to rule out an EMC on Patient 24 throughout the patient's five-minute stay.

During an interview/phone call on 10/04/21 at 10:45 AM, Patient 24, stated that she fell in the early morning of 9/25/21 over a child safety gait, landed on her stomach and her left side. "I really felt ok, but I was just worried there might be something wrong. I called my mother and she said I should be seen." She stated that she, her finance, and two children went to the ED. This was somewhere between 10:30 AM and 11:00 AM, but she cannot recall the exact time. She stated that she was not experiencing abdominal pain or vaginal spotting or bleeding. Upon arrival she told the female (unknown name) setting behind the window her name, other information and the reason she was seeking services. She stated that she was told to take a seat in the waiting area. After a few minutes a male (unknown name) came to her in the waiting room and told her "unfortunately we do not have the fetal monitoring equipment to check on the baby." He then asked her where her primary care physician was. Patient 24 stated that he replied to her options would be to go to another facility to be seen. He suggested she go where you are already established by a Primary Care Physician (PCP). Patient 1 stated that she was not taken back to an exam room, received any form of medical exam and or did not sign any documents at the ED, before exiting the ED.

During an interview on 10/04/21 at 1:15 PM, Staff C, ED Director, stated that when a patient arrives at the registration desk and request to be seen by ED staff, the registration staff enter the patient on the ED log. Nursing staff then retrieve the patient from the waiting room, perform a triage assessment, and then place the patient in a room. The provider then performs a MSE to determine if a MEC exists.

During an interview on 10/05/21 at 8:33 AM, Staff D, ED Advanced Registered Nurse Practitioner (ARNP), stated that he did speak with Patient 24 in the ED on 09/25/21. He stated that Patient 24 relayed to him, that she had fallen earlier in the day, and she informed registration staff that she was wanting a fetal sonogram (a computerized picture of items in the body). Staff D stated that he informed Patient 1 that the facility did not have that type of procedure available at the Off-Campus ED, and suggested she be seen by her PCP or another facility. He did not know if the patient was registered on the ED log, doesn't recall seeing a face sheet for Patient 24, and recalls that the facility was having problems with the computer system that weekend. Staff D stated that he did not perform a MSE to determine if a MEC was present. He did not chart that the patient had declined to be seen. He did not document the risks of leaving before an MSE could be completed. Staff D stated that he was contacted by Staff B, CNO, sometime last week about a possible EMTALA violation, if he could recall the patient's name, because the patient could not be found on the ED log. Staff D stated that he was contacted the previous day by Staff E, Chief Executive Officer (CEO) regarding his contact with Patient 24.

During an interview/phone call on 10/05/21 at 10:30 AM, Staff H, Registration Receptionist, stated that when patients arrive in the ED, she asks them why they are requesting to be seen, their name, date of birth, she signs into the system, and makes a profile for the patient. They sign the consent for treatment, and placed into MedHost. Staff H stated that a couple weeks prior, a female came into the ED via the registration desk, and asked to be seen. The patient stated she fell at home, was 35 weeks pregnant, was concerned about the well-being of the baby, and wanted to be seen. The patient was checked in as a fall injury. Staff H stated she called back to the ED nurse's station to notify staff of arrival. Stated that Staff D, ARNP, came out to see the patient in the waiting room hallway. She stated that Staff D had informed Patient 1 that the ED could see her, but did not have ultrasound capabilities. Patient should follow up with her PCP or go to another facility. Stated that the patient then left the facility without a MSE performed to see if a MEC was present.

During an interview on 10/04/21 at 12:37 PM, Staff B, CNO, stated that she was notified of a possible EMTALA violation on 09/28/21. The violation involved a female, 35 weeks pregnant, who was seen at another facility. Stated that her receptionist initially took the call, and then passed it on to her. She then passed the information on to Staff C, ED Director, and to Staff F, ED RN. Staff B stated that she has interviewed Staff F, Staff H, and Staff D. She contacted Staff G, on 09/29/21, and asked if the patient could be located on the ED log. Staff D was emailed a second time, on 10/04/21 to verify patient. Patient was not located on the ED log. States that a MSE was not performed to determine if a MEC was present at the time she was in the ED.

Based on policy review, record reviews, and interviews, the hospital failed to ensure each patient who came to the emergency department (ED) had treatment to stabilize their emergency medical condition (EMC) for two patients (Patients 8 and 12) of four ED records reviewed for stabilizing treatment prior to transfer from a sample of 24 patients. This failure had the potential to affect all patients presenting to the ED who required stabilizing treatment prior to be transferred to another hospital.

Findings Include:

Patient 8

Review of Patient 8's medical record (EMR) showed he was uninsured and presented to the ED on 06/28/21 at 3:15 PM. Review of the "Physician Documentation" by Physician (PHYS) 1, indicated Patient 8 presented to the ED via police with complaints of chest pain, a history of congestive heart failure (CHF) that Patient 8 had not been following up with, complaints of right upper quadrant (RUQ) pain for which Patient 8 had a history of gallstones, and Patient 8 reported having a large kidney stone that needed to be removed. The medical record showed Patient 8 had a past medical history of hypertension and myocardial infarction (heart attack).

Review of Patient 8's vital signs, located under the "Medical Record" tab under the "Print Medical Record" tab, indicated the following blood pressure (BP) and pulse readings taken on 06/28/21:

3:31 PM BP 192/124, pulse 87
4:01 PM BP 187/120, pulse 88
4:18 PM BP 186/119, pulse 94
4:47 PM BP 189/121, pulse 90
5:02 PM BP 192/116, pulse 93
5:17 PM BP 186/120, pulse 101
5:32 PM BP 193/123, pulse 91
6:02 PM BP 188/130, pulse 97
7:21 PM BP 195/131, pulse 95

Review of the American Heart Association's web site showed there are five blood pressure ranges as recognized by the American Heart Association:

1. Normal: Blood pressure numbers of less than 120/80 are considered within the normal range ... ... 5. Hypertensive crisis: This stage of high blood pressure requires medical attention. If your blood pressure readings suddenly exceed 180/120, wait five minutes and then test your blood pressure again. If your readings are still unusually high, contact your doctor immediately. You could be experiencing a hypertensive crisis. If your blood pressure is higher than 180/120 and you are experiencing signs of possible organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision or difficulty speaking, do not wait to see if your pressure comes down on its own. Call 911.


Review of PHYS 1's documentation on 06/28/21 at 3:15 PM showed, ". . . not given Aspirin in the Emergency Department, patient took Aspirin within the past 24 hours. Thrombolytics: are not indicated. . . had a detailed discussion with the patient and/or guardian regarding . . . Patient has what appear to be multiple chronic issues. This was discussed [sic] the patient that he needs to follow-up for his kidney stone Long's gallstones however at this time [sic] one of them. Reinfected early acute emergency . . . patient's troponin did not have a significant change. EKG did not demonstrate any type of acute myocardial injury. Patient will be discharged back to the jail however the jail was advised the patient will need close follow-up in the next few days where he will need to see a surgeon and a urologist."

Review of the CT scan of the abdomen and pelvis completed on 6/28/21 showed, Impression: 1. RIGHT renal pelvis stone (kidney stone) with mild obstructive uropathy (a condition in which the flow of urine is blocked), 2. Cholelithiasis (stones in the gall bladder).

Review of Patient 8's "Nurse's Notes" documented by RN 8 on 06/28/21 at 3:16 PM, indicated "complains of pain in chest Pain radiates to back Pain is currently 10 out of 10 (Scale of 0-10, 10 being the worst pain) on a pain scale. . . Chest pain is described as moderate, quality is stabbing, radiates to left arm(s) back began 1 day ago."

Review of the "Disposition Summary" indicated on 06/28/21 at 8:29 PM Patient 8 was discharged to police in a stable condition with a diagnosis of kidney stone in the renal pelvis and cholelithiasis.

The medical record did not show evidence that patient 8's emergency medical condition was stabilized. The medical record showed no medications were administered to treat Patient 8's high blood pressure or pain prior to discharging him back to jail.

During a telephone interview on 08/26/21 at 11:22 AM, when PHYS 1 was asked how a patient with the above-listed blood pressure values and pain reported as a pain level of 10 out of 10 by the patient could be considered stable for discharge, PHYS 1 stated "a lot of times a lot of research says to not address hypertension [HTN] in ER [emergency room] now. PHYS 1 stated he/she didn't remember Patient 8's name, but if Patient 8 was the patient PHYS 1 was thinking about, "there was a problem with narcotics in the jail, and that might be the reason why I wasn't giving pain medicine at that time . . ."


Patient 12

Review of Patient # 12's medical record showed he was uninsured and presented to the hospital's off-campus ED in Independence, KS with the police on 11/10/2020 at 9:55 PM due to an alteration in his mental status. Patient 12's diagnoses included, balanitis (swelling of the penis), auditory hallucinations (hearing things), essential (primary) hypertension, unspecified diastolic (congestive) heart failure, and hyperglycemia (high blood sugar). Further review indicated Patient 12 was brought to the ED for involuntary psychiatric medical clearance prior to transport to Hospital E (a psychiatric hospital) which had already accepted Patient 12 once medically cleared.

The ED triage nurse documented the patient had abnormal vital signs which included an elevated BP 188/123 (normal range is 120/80 - 140/90), pulse 113, and respiratory rate 24. At 9:51 PM a 12 lead EKG (electrocardiogram) was abnormal and indicated the patient had a high heart rate (sinus tachycardia), "possible left atrial (chamber in the heart) enlargement and possible septal infarct (localized area of dead tissue resulting from the loss of blood supply), possible lateral infarct." At 10:04 PM blood test results showed an abnormally elevated BNP (brain natriuretic peptide, during heart failure, pressure builds up in the chambers of your heart and creates BNP. When the heart works harder and doesn't pump blood well, it releases this hormone in large amounts) of 2,430 (normal 0 -100), a potassium level of 5.6 (normal 3.5-5.1), glucose level of 215 (normal 74-100), creatinine (indicates poor kidney function) level of 3.8 (normal 0.70-1.30), BUN (indicates decline in kidney function) of 38 (normal 9-20) , Alk Phos (indicates liver or bone disease) level 166 (normal 38-126), Albumin (helps keep fluid in your bloodstream so it doesn't leak into other tissues) level 1.6 (normal 3.5-5.0) and a Calcium (can affect the functions of the nervous system and result in mental confusion, memory loss, hallucinations and delusions) level of 7.1 (normal 8.6-10.3). At 10:06 PM the PA documented the patient had auditory hallucinations, "symptoms were severe in the emergency department" and "responds to a female voice that is not present." Further documentation showed the patient had been involuntarily committed to a State psychiatric hospital, Hospital E and admission was pending medical clearance.

On 11/10/20 at 10:44 PM Patient 12 received Diltiazem 60 mg (used to treat high blood pressure) and Clonidine 0.1 mg (used to treat high blood pressure) by mouth. At 1:10 AM on 11/11/20 the patient received Lasix 40 mg (used to help rid the body of excess fluids) by mouth. At 1:52 AM on 11/11/20 the PA wrote orders for discharge including a prescription for Amlodipine 10 mg (used to treat high blood pressure) tablets, Lasix 20 mg tablets, and Clonidine 0.1 mg tablets. At 2:01 AM the patient's BP was 162/105, pulse 83 and respiratory rate 24. Patient 12 left the ED with law enforcement at 2:06 AM.

During an interview on 11/16/21 at 9:05 AM, Law Enforcement Officer (LEO), stated that Patient 12 was in police protective custody and that he was with Patient 12 in the ED on the night of 11/10/20. He stated that when Patient 12 was discharged from the ED, he took Patient 12 to the crisis center (local mental health center), that has two beds, and dropped him off.

During an interview on 8/25/21 at 9:20 AM the Crisis Coordinator at the local Community Mental Health Center (CMHC) stated that the State Psychiatric Hospital has a waiting list for inpatient admissions and that it can take anywhere from one day to as many as 16 days before a patient can be accepted for inpatient admission. The Crisis Coordinator stated that the CMHC tries to have a hospital keep the patient in the ED until admission to the State Psychiatric hospital can be arranged but Labette doesn't want to do that because they say they don't have the space. If the hospital ED doesn't keep the patient, the CMHC would arrange for the patient to return to their "diversion unit" (a non-medical until without the ability to monitor someone's blood pressure, etc.). The CMHC has two unlicensed staff to monitor the individual for safety. The Crisis Coordinator stated that there have been times she has been concerned about patients being at the CMHC's "diversion unit." She stated that Patient 12 came to the CMHC from Labette (on 11/11/2020) and staff were told the patient had been medically cleared. The Crisis Coordinator stated that Patient 12 looked "pretty sick" so they called EMS and law enforcement and requested the patient be taken back to the ED.

During an interview on 08/26/21 at 9:56 AM, PA 1 stated that Patient 12 was medically stable. When asked how PA 1 could consider Patient 12 stable with the documented blood pressures and abnormal lab values, PA 1 stated Patient 12 didn't have any medical emergency issues. After reviewing the ED "Physician Documentation," PA 1 stated he/she believed Patient 12 "lives" with those values (referring to lab values and blood pressure). PA 1 stated Patient 12 wouldn't allow them to provide treatment. As far as emergent conditions, PA 1 stated he/she "didn't feel like the patient needed hospitalization to treat any of those issues." PA 1 stated Patient 12 was supposed to be taken by police to Facility C with the plan to transfer to Hospital E when a bed was available. PA 1 stated he/she was aware Facility C did not have medically trained staff. PA 1 stated that at discharge he/she ordered medication to treat Patient 12's blood pressure and Patient 12's heart failure.

The medical record did not contain evidence that Patient 12's emergency medical condition was stabilized. The patient received a diuretic (Lasix) without monitoring his intake/output or appreciable improvement in his vital signs. The PA documented the patient refused IVs, at the same time the PA documented the patient displayed symptoms of psychosis and was involuntarily committed.

Approximately 14 hours after discharge from the ED, Patient 12 was taken back to the off-campus ED by the police department at 3:40 PM on 11/11/2020.


During a telephone interview on 08/25/21 at 10:10 AM, NP 1 stated that the sheriff's department stated the State Psychiatric Hospital E wanted Patient 12 more medically stable before they would accept him. NP 1 stated that while he/she was trying to arrange the direct admit to the main campus intensive care unit (ICU), it was decided by the sheriff deputy to transport Patient 12 to the ED. NP 1 stated EMS "kept the patient the entire time." NP 1 stated that he/she didn't remember if EMS brought Patient 12 into the ED or if Patient 12 remained in the ambulance. NP 1 stated he/she remembered handing the transfer form to the sheriff's officer, and they transported Patient 12 to the main campus. NP 1 stated he/she did not perform a MSE for Patient 12 on 11/11/20 before Patient 12 was transferred to Labette's Intensive Care Unit (ICU).

There was no documentation to show Patient 12 presented to the off-campus ED or that a medical screening exam (MSE) was completed by Nurse Practitioner (NP) 1 who was working in the off-campus ED when Patient 12 arrived.

Review of the 11/11/20 EMS trip report indicated EMS was summoned to Labette's off-campus ED in Independence, KS at 3:40 PM to transport Patient 12 to the hospital's main campus ICU. Upon arrival Patient 12 was found sitting in a wheelchair in a "hospital room". Further documentation showed patient 12 only allowed the EMS crew to monitor his blood pressure and pulse which ranged from 135/106 and pulse of 77 at 3:58 PM, 77/42 and pulse of 91 at 4:28 PM, 157/120 and pulse of 92 at 4:29 PM and 110/75 and pulse of 102 at 4:44 PM. Further documentation showed the ambulance arrived at the hospital's main campus at 4:44 PM.

The EMS trip report included the EMS "Physician Certification Statement" which specified on 11/11/2020 a patient (name of patient is missing from the form) required ambulance transport from the Independence ER to the main hospital campus in Parsons, KS. Further documentation showed the "medical necessity" for ambulance transport was 1) Acute Renal Failure and 2) Acute CHF (emergency medical conditions). The conditions necessitating transport by ambulance included "Patient is combative", "Medical attendant required", "Hemodynamic monitoring required enroute", "Cardiac monitoring required enroute", and Other "Psychosis." The form was signed by Advanced Registered Nurse Practitioner (ARNP) 1.

The consent for transfer was marked, "The patient is unable to consent due to his/her medical condition or incapacity, and no personal representative is available to provide or refuse consent." Hand written below the statement showed, "unable to comprehend."


Review of Patient 12's Labette ICU medical record showed he was admitted to ICU on 11/11/20 at 4:40 PM with diagnoses of Renal (kidney) failure, chronic and Psychiatric illness. He was discharged and transferred to the State psychiatric hospital on 11/13/2020 at 11:55 AM without stabilization of his emergency medical condition. The discharge summary showed Patient 12's discharge diagnosis as chronic medical renal disease; CKD (chronic kidney disease), Hypertension uncontrolled; Diastolic heart failure, Cardiac Echo needed; Schizophrenia; and Diabetes. The Hospital Course by Problem showed: "the patient refused all interventions and medications. ...He remained acutely psychotic" ...

Review of Patient 12's Initial Interview on 11/11/20 at 5:43 PM, showed Mental Status: "Incapable of giving consent, Due to: Confusion."

Review of a nurse's note dated 11/13/20 showed the following:

1:44 AM: noted weeping at right ankle ...
1:59 AM: Penis is very swollen, scrotum. Patient having some difficulty voiding when using the bathroom.
3:47 AM: Patient did not tolerate BP cuff. Patient 12 complied to put an ice pack on genital area.
8:00 AM: Lab drawn. Pitting edema (swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area) from hip to feet including penis and scrotum.
9:30 AM: confused, hallucinating, talking out continuously to no one in particular, talks to toilet in the bathroom. The cardiovascular assessment showed edema (swelling) 4 + (a very deep indention lasting more than 20 seconds) from hips to feet. The pulmonary assessment showed he was short of breath with exertion and lung sounds diminished.
11:15 AM: Physician was notified of Patient 12's elevated blood pressure and an order for Nitro-paste 0.5 inch was obtained.
12:05 PM: the note showed Patient 12's BP checked and was better after Nitro Paste.

Review of Patient 12's vital signs on 11/13/20 showed the following blood pressures:

3:47 AM BP 146/112;
9:15 AM BP 160/111;
11:14 AM BP 165/110; and
12:05 PM BP 160/95.

Review of Patient 12's lab report dated 11/12/20 at 5:15 AM, showed his BNP was 4029, CHF Stage IV (BNP level >678), at Stage IV a patient experiences discomfort with any physical activity.

At 12:10 PM on 11/13/20, Patient 12 was taken in wheelchair from the ICU to police car with a police officer in attendance and transferred 102 miles to a State Psychiatric Hospital, Hospital E.

Review of Patient 12's "Transfer Certification Form showed "Patient Is Stable for Transfer: The patient has been examined and either no EMC has been identified or any medical condition is stabilized such that, transfer is reasonably indicated, and the patient/patient's representative has consented to the transfer."

Although it was documented on the transfer form that Patient 12's was stable for transfer, his final diagnoses, labs, blood pressures and 4+ pitting edema from his hips to his feet did not indicate his emergency medical condition had been stabilized. His diagnoses included Hypertensive heart and chronic kidney disease; Acute on chronic kidney disease, stage 4 (severe); Acute kidney failure; Type 2 Diabetes mellites (DM) with diabetic chronic kidney disease; Type 2 DM with hyperglycemia (high blood sugars); Schizophrenia; ... The nursing notes showed that he had bilateral lower extremity 4 + pitting edema from his hips to his feet with weeping of his right ankle, his blood pressure remained elevated. The transfer form dated 11/13/20 at 11:55 showed his BP was 160/98.

The ICU medical record failed to show Patient 12's medical condition was stabilized prior to transferring him to the State Psychiatric Hospital E, in a car, with a police officer, 102 miles away.

Review of Hospital E's medical record showed that Patient 12 arrived at 2:40 PM on 11/13/20 via a police car and was unable to walk. Documentation in the medical record showed "While in the police car it was noticed that the patient's legs were weeping to the point that his pant leg and sock were soaked on the right leg." Further documentation showed that the patient had significant swelling in his legs and his abdomen was enlarged and firm with discoloration to the skin. "A nitroglycerin paste patch was still taped to his upper back" and he was having difficulty breathing. His blood pressure was 178/106 and his pulse (heart rate) was 106. Further documentation showed "At this time, his medical conditions are priority before efforts to assess and provide psychiatric treatment." The medical consultant called the ED physician at an acute care hospital, Hospital F, and the patient was accepted for transfer because of the acuity and severity of his medical condition.

Review of Hospital F's medical record showed Patient 12 was transported by ambulance on 11/13/20 approximately one hour after he arrived at [name of State Psychiatric Hospital]. Further documentation showed Patient 12 was examined in the ED and admitted to the hospital for treatment to stabilize his emergency medical condition.

Based on policy review, medical record reviews, and interview, the hospital failed to ensure a patient was transferred by qualified personnel and transportation equipment for two patients (Patient 4 and 12) of four emergency department (ED) records reviewed from a sample of 24 patients. Patient 4, who was experiencing suicidal ideation, was transferred to an inpatient psychiatric facility in a personal vehicle with a family member. Patient 12 had an emergency medical condition that was not stabilized prior to transfer from the Intensive Care Unit (ICU) in a police car to a psychiatric hospital that did not have the capabilities to manage his complex and unstabilized emergency medical condition. This failure had the potential to affect all patients presenting to the emergency department and who subsequently required an appropriate transfer to another facility.

Findings Include:

Review of Patient 4's "Physician Documentation" by Physician (PHYS) 1, located under the "Medical Record" tab in the electronic medical record (EMR), showed Patient 4, a 12-year-old patient who arrived via private vehicle, presented to the emergency department (ED) on 11/23/20 at 10:17 PM. PHYS 1 documented Patient 4, "presents to the emergency department with depression, suicidal ideation, but the patient has no formulated plan. . . the patient has had a prior suicide gesture ,where the patient took pills/meds, 2 week(s) ago." PHYS 1's documentation of Patient 4's exam indicated, "Psych: Behavior/mood is suicidal, depressed. Affect is flat. Oriented to person, place, time, Patient having thoughts of suicide. Denies suicidal plan."

Review of Patient 4's "Crisis Mental Status Exam" documented by Licensed Medical Social Worker (LMSW), located under the "Medical Record" tab in the EMR indicated, ". . . Hospital will arrange transportation as required by EMTALA and when EMTALA documentation completed."

Review of Patient 4's, "Interfacility Transfer Orders," located under the "Medical Record" tab in the EMR, indicated transfer patient to Hospital D with mode of transportation "car."

During an interview on 08/26/21 at 8:46 AM, when asked if the hospital had a policy or protocol about transferring patients having suicidal ideations via a personal vehicle, AVPQ stated we have a mental health policy. AVPQ reviewed the mental health policy and the EMTALA policy and stated the staff collaborate with the mental health personnel and determine the mode of transportation. AVPQ offered no explanation regarding the safety of transporting Patient 4 in a personal vehicle with a family member when Patient 4 was experiencing suicidal ideations.

Patient 12

Review of Patient 12's Labette ICU medical record showed he was admitted to ICU on 11/11/20 at 4:40 PM with diagnoses of Renal (kidney) failure, chronic and Psychiatric illness. He was discharged and transferred to the State psychiatric hospital on 11/13/20 at 11:55 AM without stabilization of his emergency medical condition. The discharge summary showed Patient 12's discharge diagnosis as chronic medical renal disease; CKD (chronic kidney disease), Hypertension uncontrolled; Diastolic heart failure, Cardiac Echo needed; Schizophrenia; and Diabetes. The Hospital Course by Problem showed: "the patient refused all interventions and medications. He remained stable and labs remained stable in the ICU. He remained acutely psychotic" ...

Review of a nurse's note dated 11/13/20 showed the following:

1:44 AM: noted weeping at right ankle ...
1:59 AM: Penis is very swollen, scrotum. Patient having some difficulty voiding when using the bathroom.
3:47 AM: Patient did not tolerate BP cuff. Patient 12 complied to put an ice pack on genital area.
8:00 AM: Lab drawn. Pitting edema (swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area) from hip to feet including penis and scrotum.
9:30 AM: confused, hallucinating, talking out continuously to no one in particular, talks to toilet in the bathroom. The cardiovascular assessment showed edema (swelling) 4 + (a very deep indention lasting more than 20 seconds) from hips to feet. The pulmonary assessment showed he was short of breath with exertion and lung sounds diminished.
11:15 AM: Physician was notified of Patient 12's elevated blood pressure and an order for Nitro-paste 0.5 inch was obtained.
12:05 PM: the note showed Patient 12's BP checked and was better after Nitro Paste.

Review of Patient 12's vital signs on 11/13/2020 showed the following blood pressures: 3:47 AM BP 146/112; 9:15 AM BP 160/111; 11:14 AM BP 165/110; 12:05 PM BP 160/95.

Review of Patient 12's lab report dated 11/12/2020 at 5:15 AM, showed his BNP was 4029, CHF stage IV (BNP level >678), at Stage IV a patient experiences discomfort with any physical activity. Labs on 11/13/20 at 8:00 AM, the day of discharge showed, BUN 38, Creatinine 3.54; calcium 7.7 and glucose was 110.

Review of Patient 12's "Transfer Certification Form dated 11/12/2020 showed "Patient Is Stable for Transfer: The patient has been examined and either no EMC has been identified or any medical condition is stabilized such that, transfer is reasonably indicated, and the patient/patient's representative has consented to the transfer."

Although it was documented on the transfer form that Patient 12's was stable for transfer, his final diagnoses, labs, blood pressures and 4+ pitting edema from his hips to his feet did not indicate his emergency medical condition was stabilized. His diagnoses included Hypertensive heart and chronic kidney disease; Acute on chronic kidney disease, stage 4 (severe); Acute kidney failure; Type 2 Diabetes mellitus (DM) with diabetic chronic kidney disease; Type 2 DM with hyperglycemia (high blood sugars); Schizophrenia; ... The nursing notes showed that he had bilateral lower extremity 4 + pitting edema from his hips to his feet with weeping of his right ankle, his blood pressure remained elevated. The transfer form dated 11/13/2020 at 11:55 showed his BP was 160/98.

At 12:10 PM on 11/13/2020, Patient 12 was taken in wheelchair from the ICU to a police vehicle for transport without the appropriate medical personnel or equipment necessary to monitor his emergency medical condition during the 102 miles trip to State Psychiatric Hospital E. State Psychiatric Hospital E did not have the capabilities to stabilize or manage the patient's complex and un-stabilized emergency medical condition.

Review of Patient 12's Psychiatric Hospital E medical record showed Patient 12 arrived "with several serious medical conditions that need to be further assessed in a medical facility. At this time, his medical conditions are priority before efforts to assess and provide psychiatric treatment ... Per Labette Health he is "medically stable and ready for discharge." [Psychiatric Hospital E] does not have the capacity to manage his medical conditions --with severe kidney disease, hypertension and reported CHF."

Review of Hospital F's medical record showed Patient 12 was transported by ambulance on 11/13/20 approximately one hour after he arrived at [name of State Psychiatric Hospital]. Further documentation showed Patient 12 was examined in the ED and admitted to the hospital for treatment to stabilize his emergency medical condition.