Nkc Health

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50321 Based on interview, document review and policy review, the hospital failed to to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care when they failed to enter one patient (#15) on the log of 22 records reviewed from 03/01/25 through 09/08/25. The hospital’s average monthly census was 3,818. Findings included: Review of the hospital’s undated policy titled, “Emergency Medical Screening, Treatment, Transfer and On-Call Roster,” showed: - A central log should be maintained of all individuals who came to the ED. An individual came to the ED when the individual presented at the hospital’s ED and requested examination or treatment for a medical condition or had such a request made on the individual’s behalf. - An EMC meant a medical condition manifesting itself by acute symptoms of sufficient severity (to include psychiatric [relating to mental illness] disturbances, such as suicidal ideation [SI, thoughts of causing one’s own death] or homicidal ideation [HI, thoughts or attempts to cause another’s death]) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily function, or serious dysfunction of any bodily organ or part. - A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether an individual had an EMC or not. - The MSE should be appropriate to the individual’s signs and symptoms. Each individual would receive and have documented in the medical record a MSE that included a behavioral health assessment, as indicated. Review of the hospital’s undated policy titled, “Care of the Suicidal, Homicidal, Unsafe Patient,” showed: - Indications that a patient was suicidal, homicidal, or unsafe may be a report from an ambulance crew, other transporters or observation of patient’s verbal and/or action behaviors. - The staff member who first received information regarding a patient’s SI or HI, or concerns for other behavioral health condition, should be responsible for documenting and alerting other staff. - For ED patients who presented with behavioral health conditions as their primary reason for care they will have a suicidal screening performed on every encounter. Medical stabilizing treatment would be provided as ordered by the ED provider. Review of the hospital’s undated policy titled, “Medical Holds for Psychiatric Patient Safety,” showed: - Medical or nursing staff should designate patients as being on a medical hold status when the patient presented a likelihood of serious harm to themselves or others. A patient on a medical hold was not permitted to leave against medical advice (AMA) and should be required to stay at the hospital which may include direct observation where appropriate and/or requesting assistance from hospital security and safety staff. - Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by a behavioral health assessor or by a psychiatrist if the patient was in the ED. - While awaiting behavioral health assessment, nursing staff should monitor the patient and take precautionary steps to ensure the safety of the patient and staff. - Any medical staff member, Registered Nurse (RN), or other staff member with knowledge that a patient was on a medical hold or temporary medical hold was authorized to detain a patient at the hospital for the patient’s safety. Please refer to A-2405 for further details.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 50321 Based on interviews, document review and policy review, the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care when they failed to enter one patient (#15) on the log of 22 records reviewed from 03/01/25 through 09/08/25. The hospital’s average monthly census was 3,818. Findings included: Review of the hospital’s undated policy titled, “Emergency Medical Screening, Treatment, Transfer and On-Call Roster,” showed a central log should be maintained of all individuals who came to the ED. An individual came to the ED when the individual presented at the hospital’s ED and requested examination or treatment for a medical condition or had such a request made on the individual’s behalf. Review of the hospital’s undated document titled, “Safety Event Action Plan,” showed: - On 06/18/25 at 4:00 PM, Staff O, Security Sergeant, received a phone call from law enforcement who advised him that Patient #15 needed a mental health evaluation. - At 4:28 PM, Patient #15 arrived with law enforcement. Law enforcement spoke with staff and were directed to the triage (process of determining the priority of a patient’s treatment based on the severity of their condition) area by Staff L, Registered Nurse (RN). While at the triage area the law enforcement officer removed Patient #15’s handcuffs and she sat in a chair. - At 4:38 PM, law enforcement left the hospital. Patient #15 walked to the triage desk. The triage desk was unattended. - At 4:41 PM, Patient #15 asked a Security Officer (SO) where the restroom was. She then went to the restroom alone. - At 4:46 PM, Patient #15 exited the hospital at the main entrance. Review of a written interview on 06/19/25, with Staff R, SO, Staff S, SO and Staff O, Security Sergeant, showed: - Staff O informed security staff that law enforcement was coming to bring an unnamed patient for a mental health evaluation. - Staff R met Patient #15 and law enforcement at the triage desk. Law enforcement informed him Patient #15 had a probate warrant (a document that orders the detention or commitment of a person for evaluation or treatment related to mental illness or substance abuse) for mental health. - A follow up note, after the interview concluded, showed that the law enforcement office was contacted after the event. A fax was successfully sent from law enforcement with the probate warrant at 3:12 PM to the hospital. Review of a written statement on 06/18/25 at 7:24 PM, Staff L, RN, showed law enforcement presented to the ambulance bay with a female patient in handcuffs. Staff L directed them to triage because there were no open rooms and advised law enforcement to check Patient #15 in there. Review of the hospital’s ED log showed Patient #15 was not listed on 06/18/25. Although requested a medical record for Patient #15 was not provided. During an interview on 09/08/25 at 10:19 AM, Staff D, ED Director, stated that Patient #15 should have been put on the ED log. It surprised her that staff had not put Patient #15 on the ED log. During an interview on 09/08/25 at 11:01 AM, Staff L, RN, stated that law enforcement had called earlier in the day to inform her about the warrant. She provided a fax number to send the court order. She directed Patient #15 to the triage desk when she arrived. She did not put Patient #15 on the ED log but should have done so.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50321 Based on interview, document review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#15) of 22 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s undated policy titled, “Emergency Medical Screening, Treatment, Transfer and On-Call Roster,” showed: - An EMC meant a medical condition manifesting itself by acute symptoms of sufficient severity (to include psychiatric [relating to mental illness] disturbances, such as suicidal ideation [SI, thoughts of causing one’s own death] or homicidal ideation [HI, thoughts or attempts to cause another’s death]) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily function, or serious dysfunction of any bodily organ or part. - A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether an individual had an EMC or not. - The MSE should be appropriate to the individual’s signs and symptoms. Each individual would receive and have documented in the medical record a MSE that included a behavioral health assessment, as indicated. Review of the hospital’s undated policy titled, “Care of the Suicidal, Homicidal, Unsafe Patient,” showed: - Indications that a patient was suicidal, homicidal, or unsafe may be a report from an ambulance crew, other transporters or observation of patient’s verbal and/or action behaviors. - The staff member who first received information regarding a patient’s SI or HI, or concerns for other behavioral health condition, should be responsible for documenting and alerting other staff. - For ED patients who presented with behavioral health conditions as their primary reason for care they will have a suicidal screening performed on every encounter. Medical stabilizing treatment would be provided as ordered by the ED provider. Review of the hospital’s undated policy titled, “Medical Holds for Psychiatric Patient Safety,” showed: - Medical or nursing staff should designate patients as being on a medical hold status when the patient presented a likelihood of serious harm to themselves or others. A patient on a medical hold was not permitted to leave AMA and should be required to stay at the hospital which may include direct observation where appropriate and/or requesting assistance from hospital security and safety staff. - Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by a behavioral health assessor or by a psychiatrist if the patient was in the ED. - While awaiting behavioral health assessment, nursing staff should monitor the patient and take precautionary steps to ensure the safety of the patient and staff. - Any medical staff member, Registered Nurse (RN), or other staff member with knowledge that a patient was on a medical hold or temporary medical hold was authorized to detain a patient at the hospital for the patient’s safety. Review of a document titled, “Order for 96-Hour (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) Detention, Evaluation and Treatment and Warrant,” dated 06/18/25, showed: - Patient #15 had a history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and previous psychiatric hospitalizations related to SI and HI statements. - An order, signed by a judge, documented Patient #15 made suicidal and homicidal statements and refused to take her psychiatric medications. - She needed detention, evaluation, and treatment related to the likelihood that she was at risk of serious harm toward herself or others. - Her father completed an affidavit (a written statement confirmed by oath, for use as evidence in court) that documented Patient #15 had previously been admitted to a hospital in Kansas where she was recommended to be involuntarily held (a legal process through which a person is hospitalized and treated for mental health disorders without their consent). She was released without family knowledge, refused to take her prescribed medications, made threats to harm herself and believed her children were dead. She was found to have slept in the woods and was homeless without the ability to make safe decisions that her family felt would lead to her death or harm to others if she did not receive help immediately. - Her daughter completed an affidavit that documented Patient #15 had called her with threats to kill herself and those around her. Patient #15 believed someone had stolen her identity and had used it to get her into trouble, that she was pregnant with twins, and that the government was lying to her about a car. She was living in the woods for a few weeks with a man, despite having a place to live. She had recently stolen her sister’s car, threatened several family members for money and had threatened to kill herself. Her daughter found drug paraphernalia in her car after she gave Patient #15 a ride. Her behavior escalated and became more erratic and bizarre. Review of a police report, dated 06/18/25, showed: - At 3:53 PM, Patient #15 was arrested on a probate warrant (a document that orders the detention or commitment of a person for evaluation or treatment related to mental illness or substance abuse). - The responding officer called the hospital to explain the content of the warrant. - Patient #15 was left with hospital security who advised the responding officer that they would check her into the hospital. Review of the hospital’s undated document titled, “Safety Event Action Plan,” showed: - On 06/18/25 at 4:00 PM, Staff O, Security Sergeant, received a phone call from law enforcement who advised him that Patient #15 needed a mental health evaluation. - At 4:28 PM, Patient #15 arrived with law enforcement. Law enforcement spoke with staff and were directed to the triage (process of determining the priority of a patient’s treatment based on the severity of their condition) area by Staff L, RN. While at the triage area the law enforcement officer removed Patient #15’s handcuffs and she sat in a chair. - At 4:38 PM, law enforcement left the hospital. Patient #15 walked to the triage desk which was unattended. - At 4:41 PM, Patient #15 asked a Security Officer (SO) where the restroom was. She then went to the restroom alone. - At 4:46 PM, Patient #15 exited the hospital at the main entrance. Review of a written interview on 06/19/25, with Staff R, SO, Staff S, SO, and Staff O, Security Sergeant, showed: - Staff O had informed security staff that law enforcement was coming to bring an unnamed patient for a mental health evaluation. - Staff R met Patient #15 and law enforcement at the triage desk. Law enforcement informed him Patient #15 had a probate warrant for mental health. - Staff O believed law enforcement thought they had fulfilled their obligation but did not confirm the hospital had received the court order paperwork. - A follow up note, after the interview concluded, showed the law enforcement office was contacted after the event. A fax was successfully sent from law enforcement with the probate warrant at 3:12 PM to the hospital. Review of a written statement on 06/18/25 at 7:24 PM, Staff L, RN, showed law enforcement presented to the ambulance bay with a female patient in handcuffs. Staff L directed them to triage because there were no open rooms and advised law enforcement to check Patient #15 in there. She was later informed Patient #15 had left the building. An hour prior to the incident she received a call from law enforcement, and they informed her that they were going to bring a patient on a probationary matter and asked for a fax number to provide paperwork. Review of the hospital’s undated document titled, “North Kansas City Documents,” showed: - On 06/18/25, an investigation began related to Patient #15’s elopement. She had left the hospital prior to the completion of a MSE. - Root causes for the event included non-receipt of court paperwork from law enforcement, lack of closed loop communication, workflow and process gaps, an unattended triage desk, a full ED, and a need for EMTALA education. - As a result of the investigation all security and ED staff received education related to EMTALA requirements and process changes. When a patient arrived at the ED with law enforcement security staff were to inquire as to the reason for presentation and escort the individual to the charge nurse desk for supervision. A formal handoff would take place between law enforcement and security staff. The triage desk was to always have staff present. - Education would be captured by email read receipt and attestations. - Formal audits were completed by leadership. Security staff would be audited for 100% of individuals accompanied by law enforcement starting on 06/25/25 and continue for four weeks for the reason the individual presented, all other audits would begin on 06/20/25. - Education attached included the “Care of the Suicidal, Homicidal, Unsafe Patient,” “Medical Holds for Psychiatric Patient Safety,” “Security Alert - Missing Person,” and “Patient Safety Events Including Sentinel Events,” policies and EMTALA training. - Completed attestations showed ED and security staff received education beginning on 06/19/25. Although requested, a medical record for Patient #15 was not provided. Although requested, an interview with Staff R, SO, was not provided as he was no longer employed with the hospital. The law enforcement officer did not respond to several requests for an interview. During an interview on 09/09/25 at 10:19 AM, Staff D, ED Director, stated that all ED and security staff had received Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) education related to MSE obligations as a result of the event on 06/18/25, when Patient #15 eloped (when a patient makes an intentional, unauthorized departure from a medical facility) before she received a MSE. If there were mental health concerns, she expected security staff to know to watch the patient and not allow them to leave. A patient who arrived with law enforcement for mental health concerns should not have been directed to the triage desk, which should not have been unattended. During a telephone interview on 09/09/25 at Staff O, Security Sergeant, stated that since Patient #15’s elopement security staff had received education that explained what a probate warrant was, and the education had been added to new hire education. He would expect security staff to know that if a patient needed a mental health examination, they could not leave the hospital. During an interview on 09/09/25 at 11:01 AM, Staff L, RN, stated that she would have expected security staff to have known that patients with SI should not be left alone. Since the event all ED and security staff received education related to EMTALA. A new policy required clinical staff to always be present at the triage desk, and all patients brought in by law enforcement for mental health concerns were brought to the CN desk directly. During an interview on 09/08/25 at 12:34 PM, Staff H, Security Seargent, stated that if someone was accompanied by law enforcement, they had a checklist to complete, regardless of if they arrived by ambulance or were a voluntary admission. If they arrived with law enforcement, they would stay with the patient until a clinical person was assigned to the patient, and the checklist and handoff were complete. Psychiatric patients who arrived with law enforcement went through triage straight to the CN. This is cited as previous non-compliance, the hospital identified, corrected and had preventative measures in place prior to the survey entrance.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46856 Based on interview, record review and policy review, the hospital failed to follow their policies to identify an emergency medical condition (EMC) and to provide a safe, appropriate discharge for one patient (#1) out of 31 Emergency Department (ED) records reviewed for patients that presented to the ED from 07/05/24 through 01/13/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 6,943. Findings included: Review of the hospital’s undated policy titled, “Emergency Medical Screening, Treatment, Transfer and On-Call Roster,” showed any individual who comes to the ED of this hospital shall receive a MSE performed by Qualified Medical Personnel (QMP) to determine whether that individual is experiencing an EMC. The MSE shall be appropriate to the individual’s signs and symptoms, as well as the capability and capacity of the hospital. ED staff shall attempt interventions with any individual indicating a desire to leave the ED prior to receiving a MSE. ED staff shall advise an individual indicating a desire to leave of the risks of refusing a MSE and assess that individual’s capacity to understand those risks. If staff are concerned the individual has a psychiatric (relating to mental illness) disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, staff should implement the policy “Medical Holds for Psychiatric Patient Safety” and staff may request assistance from Security. Disruptive, inappropriate, or erratic behavior may be an indication of an underlying EMC, and QMP must carefully assess the patient’s capacity to understand the situation and information provided. Review of the hospital’s undated policy titled, “Rules and Regulations of the Medical Staff,” showed that members of the medical staff shall comply with the NKCH policy entitled “Emergency Medical Screening, Treatment, Transfer and On-Call Roster.” In accordance with the policy and federal law, all individuals who come to the hospital’s ED shall receive a MSE by a QMP, will be provided stabilizing treatment and, when necessary, an appropriate transfer. Review of the hospital’s undated policy titled, “Medical Holds for Psychiatric Patient Safety,” showed NKCH Medical Staff Members or Nursing Staff shall designate patients as being on a Medical Hold status when the patient presents a likelihood of serious harm to themselves or others. The determination of whether a patient is likely to harm him/herself or others shall be based on clinical assessment and may be due to a patient’s psychiatric disturbance or substance abuse. A patient on a medical hold is not permitted to leave against medical advice (AMA) and should be required to stay at NKCH using the least restrictive means. This may include, but is not limited to, initiating the restraint usage policy or direct observation where appropriate, and/or requesting assistance from Security. A medical hold is a designation to help assure patient safety and is not a legal process and does not require a court order. When a patient appears to have a psychiatric disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, nursing staff should confirm that a physician has assessed the patient’s medical stability and has requested a psychiatric evaluation. Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by a Behavioral Health Assessor or by a psychiatrist (physician who specializes in mental health disorders). NKCH staff caring for psychiatric patients and others present at the hospital with personal knowledge of the patient’s condition or behavior (such as friends and family, first responders, and law enforcement) should complete the Department of Mental Health form 142 Affidavit (a written statement confirmed by oath, for use as evidence in court). Staff should facilitate the completion of affidavits by others present at the hospital with personal knowledge of the patient’s condition. The presence of an affidavit on the medical record does not automatically mean that the patient is on a medical hold. An affidavit is not required to be on the medical record to detain a patient at NKCH for the patient’s safety. Review of the hospital’s undated policy titled, “Care of the Suicidal/Homicidal/Unsafe Patient,” showed that staff should follow this policy when providing to care for unsafe patients, including patients with behavioral health/psychiatric complaints, suicidal ideation (SI, thoughts of causing one’s own death), homicidal ideation (HI, thoughts or attempts to cause another’s death), or substance abuse problems. The goal is to provide the safest environment possible and to minimize the potential for harm to the patient, visitors, staff, and others. Indications that a patient has SI, HI, or is unsafe may include a report from an ambulance crew, other transporters or observation of patient’s verbal and/or behaviors. Certain symptoms or disorders may provide indications that a patient is or may become SI, HI, or unsafe. Symptoms/disorders which can lead to SI/HI include disorientation (experiencing delusions or hallucinations) and defiance (wanting complete control of oneself). The staff member who first receives information regarding a patient’s SI or HI, or concerns for other behavioral health conditions, shall be responsible for documenting and alerting other staff. ED patients presenting with behavioral health conditions as their primary reason for care will have a suicidal screening performed on every encounter using the Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS combined with clinical judgement can help determine levels of risk and aid in making clinical decisions about care. Review of the hospital’s undated policy titled, “Security & Safety - Security Responsibilities,” showed Security staff should: - Patrol the facility, adjacent parking areas and premises; - Assist patients, visitors, and employees in reasonable requests for service or guidance; - Be alert for and document potentially hazardous situations and conditions on hospital premises and within the facilities; - Maintain vigilance for unsafe acts, events or situations; and - Assist with transfer to the hospital of personnel who cannot get to the hospital during inclement weather. Review of the hospital’s undated policy titled, “Security,” showed that the hospital’s Security staff provides protection for employees, patients and visitors. Security also monitors the hospital’s buildings, equipment, and supplies, and is alert to potentially hazardous situations or conditions. Security officers patrol the facilities, adjacent parking areas, and premises to assist employees, patients, and visitors. Security and safety are the responsibility of every NKCH staff member. For the welfare of patients, visitors and fellow employees, all staff should be alert to the presence of suspicious persons, particularly in unauthorized areas; suspicious activity of any nature; unusual findings or incidents; and circumstances which look out of place. The Security staff should be notified immediately in the event of such occurrences. Review of the hospital’s undated policy titled, “ED - Discharge of Patient from the Emergency Department,” showed that the ED follows the general guidelines for the discharge of a patient from the hospital. Review of the hospital’s undated policy titled, “Discharge,” showed that a discharge plan is developed based on individual needs and discussed with the patient and/or caregiver. The nurse will review discharge instructions with the patient. Any patient requiring transportation from the hospital must have documentation from case management and/or the Director of Clinical Operations. Discharge considerations for winter weather included a winter storm warning (heavy snow of six inches in 12 hours or eight inches in 24 hours, or sleet of one-half inch or more) and/or a blizzard warning (blizzard conditions for at least three hours). 47504”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 46856 Based on interview, record review and policy review, the hospital failed to follow their policies to identify an emergency medical condition (EMC) for a one patient (#1) out of 31 Emergency Department (ED) records reviewed for patients that presented to the ED from 07/05/24 through 01/13/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 6,943. Findings included: Review of the hospital’s undated policy titled, “Emergency Medical Screening, Treatment, Transfer and On-Call Roster,” showed any individual who comes to the ED of this hospital shall receive a MSE performed by Qualified Medical Personnel (QMP) to determine whether that individual is experiencing an EMC. The MSE shall be appropriate to the individual’s signs and symptoms, as well as the capability and capacity of the hospital. ED staff shall attempt interventions with any individual indicating a desire to leave the ED prior to receiving a MSE. ED staff shall advise an individual indicating a desire to leave of the risks of refusing a MSE and assess that individual’s capacity to understand those risks. If staff are concerned the individual has a psychiatric (relating to mental illness) disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, staff should implement the policy “Medical Holds for Psychiatric Patient Safety” and staff may request assistance from Security. Disruptive, inappropriate, or erratic behavior may be an indication of an underlying EMC, and QMP must carefully assess the patient’s capacity to understand the situation and information provided. Review of the hospital’s undated policy titled, “Rules and Regulations of the Medical Staff,” showed that members of the medical staff shall comply with the NKCH policy entitled “Emergency Medical Screening, Treatment, Transfer and On-Call Roster.” In accordance with the policy and federal law, all individuals who come to the hospital’s ED shall receive a MSE by a QMP, will be provided stabilizing treatment and, when necessary, an appropriate transfer. Review of the hospital’s undated policy titled, “Medical Holds for Psychiatric Patient Safety,” showed NKCH Medical Staff Members or Nursing Staff shall designate patients as being on a Medical Hold status when the patient presents a likelihood of serious harm to themselves or others. The determination of whether a patient is likely to harm him/herself or others shall be based on clinical assessment and may be due to a patient’s psychiatric disturbance or substance abuse. A patient on a medical hold is not permitted to leave against medical advice (AMA) and should be required to stay at NKCH using the least restrictive means. This may include, but is not limited to, initiating the restraint usage policy or direct observation where appropriate, and/or requesting assistance from Security. A medical hold is a designation to help assure patient safety and is not a legal process and does not require a court order. When a patient appears to have a psychiatric disturbance or substance abuse condition and may present a likelihood of serious harm to self or others, nursing staff should confirm that a physician has assessed the patient’s medical stability and has requested a psychiatric evaluation. Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by a Behavioral Health Assessor or by a psychiatrist (physician who specializes in mental health disorders). NKCH staff caring for psychiatric patients and others present at the hospital with personal knowledge of the patient’s condition or behavior (such as friends and family, first responders, and law enforcement) should complete the Department of Mental Health form 142 Affidavit (a written statement confirmed by oath, for use as evidence in court). Staff should facilitate the completion of affidavits by others present at the hospital with personal knowledge of the patient’s condition. The presence of an affidavit on the medical record does not automatically mean that the patient is on a medical hold. An affidavit is not required to be on the medical record to detain a patient at NKCH for the patient’s safety. Review of the hospital’s undated policy titled, “Care of the Suicidal/Homicidal/Unsafe Patient,” showed that staff should follow this policy when providing to care for unsafe patients, including patients with behavioral health/psychiatric complaints, suicidal ideation (SI, thoughts of causing one’s own death), homicidal ideation (HI, thoughts or attempts to cause another’s death), or substance abuse problems. The goal is to provide the safest environment possible and to minimize the potential for harm to the patient, visitors, staff, and others. Indications that a patient has SI, HI, or is unsafe may include a report from an ambulance crew, other transporters or observation of patient’s verbal and/or behaviors. Certain symptoms or disorders may provide indications that a patient is or may become SI, HI, or unsafe. Symptoms/disorders which can lead to SI/HI include disorientation (experiencing delusions[false ideas about what is taking place or who one is] or hallucinations [seeing or hearing things which are not there]) and defiance (wanting complete control of oneself). The staff member who first receives information regarding a patient’s SI or HI, or concerns for other behavioral health conditions, shall be responsible for documenting and alerting other staff. ED patients presenting with behavioral health conditions as their primary reason for care will have a suicidal screening performed on every encounter using the Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS combined with clinical judgement can help determine levels of risk and aid in making clinical decisions about care. Review of the hospital’s undated policy titled, “Security & Safety - Security Responsibilities,” showed Security staff should: - Patrol the facility, adjacent parking areas and premises; - Assist patients, visitors, and employees in reasonable requests for service or guidance; - Be alert for and document potentially hazardous situations or conditions on hospital premises and within the facilities; - Maintain vigilance for unsafe acts, events or situations; and - Assist with transfers to the hospital during inclement weather. Review of the hospital’s undated policy titled, “Security,” showed that the hospital’s Security staff provides protection for employees, patients and visitors. Security also monitors the hospital’s buildings, equipment, and supplies, and is alert to potentially hazardous situations or conditions. Security officers patrol the facilities, adjacent parking areas, and premises to assist employees, patients, and visitors. Security and safety are the responsibility of every NKCH staff member. For the welfare of patients, visitors and fellow employees, all staff should be alert to the presence of suspicious persons, particularly in unauthorized areas; suspicious activity of any nature; unusual findings or incidents; and circumstances which look out of place. The Security staff should be notified immediately in the event of such occurrences. Review of Police Department D’s report, titled “Offense/Incident Report,” dated 01/05/25, related to Patient #1, showed that Staff LL, Corporal for Police Department D, was dispatched on 01/05/25 at approximately 11:11 AM to a casino regarding a female who was trespassing. Upon arrival, he was contacted by security who advised that the female claimed to work there, was trying to access employee only areas, she seemed confused and believed the casino was Costco. Staff LL contacted the female (Patient #1). She was very abrasive and refused to answer questions. She did state that she thought it was 2024, Friday, that she was in Kansas City, and that the casino was or used to be a Costco. Patient #1 appeared to be suffering from some form of mental health issue that limited her ability to answer questions correctly or to know where she was. Patient #1 was clearly in a delusional state of mind. EMS was requested for Patient #1 due to her failure to answer questions in conjunction with the winter storm which limited her ability to go anywhere safely. Patient #1 persistently refused to answer questions and was physically forced onto the stretcher for transportation to the hospital. Staff used a firm grip when assisting her onto the stretcher. She was clearly upset but appeared to understand the need to cooperate with Fire Department B. She was transferred to NKCH without any other incidents. It was unclear as to how she came to be at the casino. She claimed to have driven, but due to the winter storm, it seemed unlikely. Review of Fire Department C’s EMS record, related to Patient #1, dated 01/05/25, showed that EMS was dispatched to the casino for a patient with an altered mental status (mental functioning ranging from slight confusion to coma). Multiple Police Department D units were on scene prior to EMS arrival. Patient #1 was found standing upright in the exit atrium area of the casino. She presented as alert and oriented to self only. She was able to speak and answer some questions appropriately. Police Department D told EMS that the patient had been there for approximately six hours and was disoriented to where she was. She repeatedly told police that she thought the casino was a “Costco” and that her house was at the casino. She refused to answer any orientation questions or allow EMS to obtain any vital signs (VS, measurements of the body’s most basic functions). She continued being uncooperative, despite many attempts by EMS and law enforcement attempts to initiate care. Casino security told the police that they did not want her on the property. This was relayed to the patient, she was informed that if she did not accept care, she could be arrested. Fire Department B EMS arrived on scene and her care was transferred to their staff. The attending medic was given a summary of the patient’s complaints, findings, and treatments. Patient #1 continued to be uncooperative. Eventually, a decision was made to place her in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and to transport her to the hospital due to her altered mental status. Police Department D was able to maneuver her to the stretcher. Once she was on the stretcher, she calmed down and no restraints were needed. Her physical assessment indicated no abnormal findings. Her Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 14. The EMS primary impression was excited (agitated) delirium (an abrupt change in the brain that causes confusion). Patient #1 was transported by Fire Department B EMS to NKCH. Review of Fire Department B’s EMS record, related to Patient #1, dated 01/05/28, showed that EMS was dispatched to the casino along with Fire Department C and Police Department D for a reported behavioral health issue. The patient was confused/disoriented and not wanting to cooperate with Fire, EMS, or Police. Casino security reported making contact with Patient #1 at approximately 6:00 AM. She was observed via a security camera attempting to go into restricted areas of the casino, cleaning the restroom, and reporting to security that she was an employee. Upon arrival, Patient #1 was found to be walking on scene, agitated, anxious, angry/upset, not making any sense, and her thought process was all over the place. She was alert and talking but did not want to answer any questions for EMS. Her physical assessment showed no abnormal physical findings. Her VS were within normal limits. Her GCS was 14. She was mentally unstable, and Police Department D staff had to physically assist her on to the stretcher. She did not want to be transported and reported that she was perfectly fine. Once she was placed on the stretcher, she was secured, monitored and transported to NKCH. Review of Patient #1’s ED record, dated 01/05/25, showed the following: - She was a 63-year-old female with no past medical history listed. Her sister was listed as an emergency contact, but there was no working telephone number listed. - The pre-arrival report sheet noted that Patient #1 was found wandering around the casino, was angry, and her vital signs were stable. - Bedside report indicated that she had been walking outside and had no complaints. There was no medical history, allergies, medications and/or drug or alcohol use listed. - Neither the pre-arrival nor the bedside report indicated that Patient #1 was confused. - On 01/05/25 at 12:23 PM, she was brought in via EMS after being found walking around the casino. - At 12:27 PM, Staff T, ED RN, documented that Patient #1 was found wandering around the casino, was kicked out, and became angry. She had no complaints at that time and denied SI and HI. Her temperature was slightly elevated at 99.5 degrees along with her blood pressure of 158/98. She denied any pain. Her C-SSRS score was zero and her GCS was 15. - At 12:39 PM, Staff U, ED Physician, documented that Patient #1 had no medical complaints. She was upset she was there. She was somewhat confused and would not give him a definitive reason why she was at the casino that morning. It was not clear how she got to the casino or why she went there in the first place. She was alert and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). She knew she was at the hospital, she told Staff U her address which matched the one listed on her driver’s license. She did leave the house that morning, and she lived at home with her dog and cat. She did not want to have anything done in the ED and requested that they help her get home. Her speech was normal, her movements were coordinated, and her cognition appeared normal. Her VS were within normal limits. She was able to answer all of Staff U’s other questions appropriately. Documentation indicated that Staff U did not believe that the hospital had the right to hold her down and/or force medical care on her. This included laboratory testing and obtaining a urinalysis (a laboratory examination of a person’s urine). She did not appear to be under the influence of any drugs or alcohol, she exhibited no acute hallucinations, delusions, or psychosis (mental illness characterized by defective or lost contact with reality). - At 1:05 PM, Staff T, ED RN, documented that Patient #1 was discharged to home. Her BP was slightly elevated at 159/91, her GCS was 15 and she denied any pain. - Her total length of stay in the ED was 42 minutes. Review of the hospital’s event report titled, “Current Summary,” dated 01/07/25, showed that on 01/06/25 at 7:40 AM, Staff CC, Cardiac Progressive Care Unit (PCU, a telemetry [remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring) RN, was alerted by the wife of Patient #30 to a questionable object outside of Patient #30’s window. Staff CC saw what appeared to be a long dark object, but visibility was low. Staff CC notified security and asked them to check on the suspicious object. She explained to security that the shape resembled a body and it looked out of place. Security indicated that they would send someone to check. Two hours later, Staff CC entered into Patient #31’s room to pass medications and perform an assessment. Patient #31 was standing by the window and looking out. She asked Staff CC what she thought was on the ground. The light was better at that time. Staff CC looked out and clearly saw a body lying on their right side in the snow. The body did not move. Staff CC called security again, at 9:45 AM. She informed them that she had called earlier, but no one had checked on the situation. There were no tracks in the snow and the object was clearly a body. The security guard stated that they would send someone to check. Review of the hospital’s security report titled, “Incident Report,” dated 01/07/25 at 11:45 AM, showed on 01/06/25 at approximately 9:39 AM, Staff D, Security Officer, was dispatched to the Professional Building for a reported person down. Staff CC, Cardiac PCU RN, reported observing, from the 10th floor Cardiac PCU, what she believed was a person lying in the snow. Upon his arrival, Staff D noticed a person lying on the ground near the electrical boxes below the handicap parking, near the building. The person appeared to be without signs of life. He called out to the individual without response and tapped her on the shoulder. She felt cold to the touch and solid as if rigor mortis (stiffening of the joints and muscles of the body a few hours after death) had set in. Staff D notified Staff EE, Security Dayshift Sergeant, of the situation and requested that EMS and Police Department E be called. EMS responded and found no vital signs and no signs of life. Staff EE notified Staff X, Director of Clinical Operations, and the Security Supervisor. Staff D remained at the scene until Police Department E arrived. The medical examiner removed Patient #1’s body at approximately 12:45 PM. Staff Y, Lead Ground Maintenance, stated he observed Patient #1 near the main entrance appearing to attempt to get into the building on 01/05/25 at approximately 2:50 PM. Security video review showed Patient #1 coming out of triage with a nurse. Patient #1 entered security’s vehicle and was dropped off at the bus stop located on the hospital’s campus. Several buses had come and gone. When security dropped off another discharged patient at the bus stop, they appeared to check on Patient #1, that was between 1:06 PM and 1:45 PM. At 1:47 PM, Patient #1 walked down to the area near the Professional Building, where she was later found. At 1:50 PM, Patient #1 appeared to attempt to enter the main entrance of the Professional Building. At 1:52 PM, she walked back down to the area near the Professional Building. Between 1:52 PM and 9:16 PM, Patient #1 paced back and forth around the Professional Building near the electrical boxes. From 9:16 PM to 11:15 PM, Patient #1 lay on the ground moving. At 11:15 PM, Patient #1 moved for the last time. It was noted that Patient #1 was outside in what appeared to be heavy snow and blizzard like conditions. A supplemental report, dated 01/06/25 at 5:00 PM, Staff EE, Security Dayshift Sergeant, was instructed by the Security Supervisor to return to the scene of the incident to attempt to locate Patient #1’s purse. He located a grate that was ajar on the south side of the Professional Building. He looked down the shaft, below the grate and discovered a purse at 5:17 PM. Staff EE retrieved the purse. Two IDs were also found in the pit. A Plant Operations employee used a small ladder to retrieve them. On 01/07/25 at 11:02 AM, Staff II, Chief of Security, and a detective from Police Department E arrived at the security office, where the detective took possession of the purse. Review of Police Department D’s report, titled “Offense/Incident Report,” dated 01/06/25, showed that at 4:27 PM, Staff JJ, Police Department D Officer, was traveling northbound on Missouri Highway 69 crossing the Missouri River when he observed a dark vehicle in the ditch off Tremont Trafficway. While in route to check on the vehicle, he was notified by communications that Police Department E was requesting an area check of the casino for a vehicle. He advised communications that the vehicle he noted and was traveling to partially matched the provided description. Upon arrival, he confirmed the vehicle description and that the license plate matched the description of the vehicle that Police Department E had provided. The front end of the vehicle was in a ditch, with only the rear of the vehicle sticking up. At the request of his sergeant, he looked through the vehicle’s windows for Patient #1’s purse and cellular telephone. He did not see anything matching the provided description and he did not open the vehicle. He contacted a tow company and the vehicle was transported to a storage facility. Review of Police Department E’s report titled, “Offense/Incident Report,” dated 01/06/23, showed the following: - Staff EE, Security Dayshift Sergeant, contacted the police department regarding a potential deceased individual. Multiple police officers responded to the scene while Fire Department B checked for signs of life. At 9:54 AM, Patient #1 was pronounced deceased. The initial responding Police Officer stated that Staff D, Security Officer, was advised by a staff nurse that there was a body lying in the snow outside. The body was found lying in the snow, on the east side of 2700 Clay Edwards Drive, south of the retaining wall. Staff D nudged the body with his foot and realized she was stiff to touch. He notified his supervisor. The time of the notification was not noted in the report. There appeared to be no obvious signs of trauma. Patient #1 had a medical bracelet on from North Kansas City Hospital that was dated 01/05/25. From 01/05/25 into 01/06/25, there were freezing temperatures and blizzard like conditions. The police officer was advised by Staff EE that Patient #1 had been brought to the hospital at approximately 12:23 PM on 01/05/25, by EMS from a local casino. She had been discharged on 01/05/25 at 1:05 PM. - Staff OO, Detective, arrived on the scene to initiate an investigation. He notified Patient #1’s sister of her death. During their interview, Patient #1’s sister stated that Patient #1 worked at Costco. Her normal working hours were 4:30 AM to 2:00 PM. She had been employed at Costco for approximately 20 years. Patient #1 did not gamble and it was “odd” that she was at the casino. Patient #1 had been previously diagnosed with a form of dementia (a loss of thinking abilities and memory). - Staff OO contacted Police Department D for additional information. Patient #1 had been found by casino security wandering around and attempting to get into restricted areas. She was combative and refused to leave, so security called the police. Dispatch stated that Police Department D had been dispatched to the casino at 11:11 AM and that Fire Department B had been dispatched at 12:00 PM. Patient #1 was transported for altered mental status to North Kansas City Hospital by Fire Department B. Staff OO reviewed the body camera footage of the officers that responded to the casino, which showed that Patient #1 was confused as to where she was and thought she was at Costco. Her vehicle was found off the roadway in a ditch about three to four blocks from the casino. - Staff OO, contacted Costco, Patient #1’s place of employment. Management acknowledged that Patient #1 had some memory issues. At times, she did not know where she was while at work, failed to clock in or out, and at times did not know what she was doing at work. - On 01/06/25 at 5:45 PM, Staff OO was notified that Patient #1’s purse was found, 25 yards away from where her body had been located, sitting on a grate. The contents of the purse had spilled down into the area beneath the grate. - On 01/07/25 at 9:00 AM, an interview was conducted with Staff CC, Cardiac PCU RN. She stated that Patient #30’s wife had asked her to look out the window to identify an object. It was dark outside, but she saw a rectangular object in the grass. She notified security regarding the object at 7:43 AM. A couple of hours later, the sun was up, and she could clearly see that the object was a body lying in the grass. She notified security again at 9:43 AM. She did not observe anyone near the body. - On 01/07/25 at 10:45 AM, Staff OO reviewed the video of Patient #1’s movements while on hospital property. Security provided a ride for Patient #1 and several other patients, to the bus stop around 1:00 PM. A short time later, when a bus arrived, she did not get on the bus. Patient #1 remained at the bus stop with several other people. Security returned and according to interview, Patient #1 failed to accept a ride to a gas station down the road, where another bus stop was located. Security transported some of the others in their vehicle and Patient #1remained standing at the bus stop alone. A short time later, security returned to the bus stop and was offered a blanket, but she declined. Patient #1 remained at the bus stop. She eventually made her way to the area where she was later found deceased. She was observed walking around that small area for the remainder of the day. She did approach the front doors of the 2700 building and was observed communicating with a person within a snow removal vehicle. Patient #1 then walked back down to the area where she was found, wandering around until 11:00 PM. At approximately 9:00 PM, Patient #1 laid down on the ground, where she was later found. She was observed lying on the ground, moving her arms and legs. rolling from side to side. She did not get up from that position and stopped moving at approximately 11:00 PM. - On 01/07/25 at 12:28 PM, an interview was conducted with Patient #31. Patient #31’s room was the last one on the hall, with two windows facing 2700 Clay Edwards Drive. She reported that on 01/05/25 at approximately 9:30 PM, she observed someone walking around in the snow outside of 2700 Clay Edwards Drive building. She informed her nurse, described as a black female with an accent, that someone was walking around in the cold weather. She stated the nurse notified security regarding the individual. When Patient #31 awoke on 01/06/25 at approximately 6:10 AM, she observed what appeared to be a body lying on the ground. She then notified Staff CC of the body. She also spoke with Patient #30’s wife who also observed the body lying on the ground. She did not observe security in the area, where the body was found, until approximately 9:40 AM. Security had been notified multiple times that someone was walking around in the cold and that Patient #1’s body was lying in the snow. Review of the hospital’s document titled, “North Kansas City Hospital Emergency Department Activity Log,” from 01/04/25 to 01/06/25, showed the following: - On 01/04/25, there were a total of 175 patients seen in the ED. - On 01/05/25, there were a total of 68 patients seen in the ED. - On 01/06/25, there were a total of 168 patients seen in the ED. Review of the hospital’s document titled, “Security Dispatch Log,” from 01/03/25 to 01/07/25, showed no documentation of any phone calls to security, on 01/05/25 or 01/06/25, regarding Patient #1. Review of the hospital’s document titled, “Security and Safety Shift Summary,” dated 01/06/25, showed on 01/05/25, from 1:05 PM to 2:10 PM, security staff transported multiple individuals to the bus stop on the hospital’s campus and the bus stop at a nearby gas station. There was no documentation of any phone calls regarding Patient #1 wandering outside the Professional Building. Review of the hospital’s document titled, “Security and Safety Shift Summary,” dated 01/07/25, showed on 01/06/25, from 7:42 AM to 8:50 AM, nine homeless discharged patients were escorted from the triage area to the cafeteria, then transported to the bus stop. At 9:41 AM, a call was received regarding a downed person. At 5:00 PM, the Security Supervisor initiated a property search. The property was located and secured. There was no documentation of any phone calls to security regarding Patient #1 lying in the snow, outside the Professional Building. Review of the National Weather Service almanac for Kansas City, Missouri, showed that on 01/05/25, the lowest temperature was 12° F, with the highest temperature of 22° F, wind chills as low as 15 below zero, and 11 inches of snowfall. Observation on 01/15/24 at 11:20 AM, from the 10th floor PCU window, showed a view of the 2700 Clay Edwards Drive building and the bus stop down the street. There were handicap parking spaces to the left of the entrance of the building, then a retaining wall and railing. Below the retaining wall was a flat area, in front of a row of windows, with an electrical transformer near the building. An additional wall blocked the view from the road. Per Staff A, Chief Operating Officer (COO), Patient #1 was found behind the additional wall, near the electrical transformer. Observation on 01/15/25 at 11:40 AM, at the bus stop where Patient #1 was dropped off, showed a significant distance between the bus stop and where Patient #1’s body was found. A State Surveyor and Staff A, COO, stood approximately where Patient #1’s body was found, near the electrical transformer, while another State Surveyor and Staff B, Vice President of Quality, stood at the bus stop. When looking from the bus stop toward where Patient #1’s body was found, it was very difficult to see the State Surveyor and Staff A, standing next to the electrical transformer, due to the distance, terrain and snowfall. From the bus stop, it was impossible to see anything on the ground next to the State Surveyor and Staff A, due to the terrain and snowfall. During a telephone interview on 01/22/25, Staff LL, Corporal for Police Department D, stated that on 01/05/25, he was called to the casino. The casino manager reported that Patient #1 was trying to get into secured areas, claimed that she worked there, and then thought she was at Costco. Patient #1 was not an employee at the casino. He spoke with Patient #1, and she was “obviously confused and not well oriented.” Patient #1 did not want to fully identify herself or to provide any family phone numbers. She “got every mental health question wrong.” She had no obvious trauma or injuries. She was dressed appropriately for walking out to the car, but not appropriately dressed for being outside for a long period of time. Patient #1 “was not capable of making her own decisions.” She thought Staff LL “was harassing her at her house,” and “seemed very confused” about who Staff LL was. Staff LL was unable to locate Patient #1’s car in the casino parking lot. He thought “something’s wrong here,” and called EMS for a mental health assessment. EMS arrived and assessed the patient. She did not want EMS to do anything and refused to let them take her blood pressure or check her blood glucose. He was told by EMS that if Patient #1 couldn’t answer four basic questions, they would have to take her to the hospital. Staff LL and the EMS crew observed the same symptoms that Patient #1 was exhibiting. She was escorted to the stretcher, and he removed Patient #1’s ID from her purse. He located a phone number for the patient’s son. Staff LL then called and left Patient #1’s son a message. Staff LL stated that the police “only fill out affidavits if patients are suicidal or a harm to themselves or others for a 96-hour hold.” During a telephone interview on 01/23/25, Staff MM, Fire Department C Lieutenant and Paramedic, stated that Police Department D requested EMS to the casino. Patient #1 could talk; she was confused and thought the casino was Costco. Later, Patient #1 thought that she was in her house. She was dressed in jeans and a jacket, which was weather appropriate. She “was definitely confused, but somewhat with it.” She started to walk out of the casino, made it about five yards out the door, then was redirected by Staff MM, who was able to convince her to return inside. Fire Department C did not have an ambulance, so Fire Department B was contacted to send an ambulance. Staff MM and the police officers tried to get Patient #1 to go to the hospital, but she was not cooperating. It “got to the point” where Staff MM asked the police officers if Patient #1 was going to be arrested for trespassing since she was uncooperative. After that, Patient #1 was guided onto the stretcher. Staff MM stated that he did not normally fill out affidavits, they were usually completed by law enforcement. During a telephone interview on 02/26/25 at 11:55 AM, Staff NN, Fire Department B Firefighter and Paramedic, stated that he was dispatched to the casino where Fire Department C and Police Department D were already on scene. When he arrived, Police Department D officers were arguing with the patient at one of the casino entrances. Patient #1 “was not making any sense, and her thought process was all over the place.” She was saying “erratic” stuff. She kept saying that they had been to her home numerous times, she kept repeating herself and would not answer questions. Casino staff reported that she had been “roaming the casino since 6:00 AM that morning,” trying to clean the restrooms and to access restricted areas. Patient #1 was not employed at the casino. There were red flags that “she was not there.” She was arguing and did not want to go to the hospital. Staff NN requested Police Department D officers to assist her to the stretcher. Once on the stretcher, she was transported to North Kansas City Hospital. While in route, she remained uncooperative. Staff NN “was not able to get a straight answer” from her. He provided a radio report to the ED and informed the nurse about Patient #1’s abnormal behaviors. When they arrived at the ED, they transferred the patient to a hospital bed and he provided a bedside report to the nurse which detailed her abnormal behaviors. Patient #1 continued to exhibit the same symptoms during the bedside report that she was exhibiting at the casino. There were no affidavits completed regarding Patient #1. Staff NN stated that if a patient constantly fought and did not want to be transported to the hospital, he would have the police officers complete an affidavit or have them respond to the ED with the patient. During an interview on 01/14/25 at 3:20 PM, Staff T, ED RN, stated that she was the nurse for Patient #1. Patient #1 arrived at the ED via EMS. She was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), appropriate and cooperative, but irritable. She was placed directly in an exam room within the ED. She received report from EMS, which was “short and simple.” EMS reported that they were called to the casino because casino security staff felt that Patient #1 had “erratic” behavior. She had refused to answer casino security’s questions and EMS staff felt that she was “altered.” Upon arrival to the ED, EMS told Staff T that Patient #1 had calmed down for them and felt that she “would be calm for her.” Staff T received most of the history from the patient. She asked Patient #1 why she was at the ED. Patient #1 told her that she was not sure why she was there and wanted to go home. Patient #1 reported no past medical history, had not ever been seen at the hospital and had no emergency contacts listed. The triage form included several behavioral health questions, including SI and whether or not the patient had a safe home environment. Patient #1 denied SI and was “very offended when she was asked those questions.” Staff T assumed that Patient #1 quit answering questions for the first responders prior to her arrival at the ED because she was irritated with them. Staff T was not present for Staff U’s, ED Physician, assessment. After Staff U completed his assessment, they compared notes. Patient #1 knew her home address, reported no complaints and wanted to go home. Staff U said that Patient #1 was appropriate for discharge and that they could not hold her. Staff U completed discharge orders and Staff T provided the discharge instructions to Patient #1. Some patients would be sent home via cab when discharged, if they did not have any family to transport them. That day, due to the inclement weather, the only options for transportation after discharge were patients’ family members or the bus system. Patient #1 indicated that she wanted to ride the bus home, her son was working and she did not want to call him. Staff T tried multiple times to get the patient to call her family to come pick her up, but she “was adamant about riding the bus home.” Patient #1 said she knew it was snowing, but she had cats at home that she needed to feed. Staff T reviewed the bus times and identified that the next bus would arrive at 1:11 PM. Staff T walked Patient #1 out to the waiting room. Security was to drive Patient #1 to the bus stop, which was down around the corner from the ED. Staff T stated that at the time of Patient #1’s ED visit, she was unaware that she had access to the EMS trip reports. She did not review EMS trip reports as part of her usual work process. She has since been educated on how to access trip tickets by management. During an interview on 01/14/25 at 3:50 PM, Staff U, ED Physician, stated that Patient #1 was brought in by EMS. By the time he assessed Patient #1, EMS had already left. The report sheet indicated she was agitated. Staff T, ED RN, reported to him that Patient #1 had become agitated, there was an altercation with casino staff, and she was told to leave. Patient #1 had never been seen at the hospital prior to this visit. There were no next of kin or contact information listed. Patient #1 told Staff U that she was poorly treated by casino staff. She was upset, and it took a while for her to calm down and to start answering questions. Patient #1 told him that she got up that morning and drove to the casino, parked in the north lot and it was snowing. Staff U asked Patient #1 why she was at the casino, but she did not seem to want to answer that. She said casino security told her to leave and she argued with them. Patient #1 allowed Staff U to do a physical exam. She answered the orientation questions appropriately, was able to state her address (which he confirmed by looking at her driver’s license) and informed him that she worked at Costco. Her vital signs were good, though her heart rate was slightly fast. Her neurological (neuro, relating to or affecting the nervous system) exam was normal, and there were no concerning physical findings. Staff U asked her if there was anyone he could call for her, and she reported that she lived alone. Staff U asked Patient #1 how she was going to get home, and she said she would take the bus home, it went right by her house. She was adamant about leaving. He was not aware of any psychiatric or behavioral problems. There was no indication for any laboratory testing or a urinalysis. She showed no signs of infection, “no red flags to be concerned about regarding mental instability or an inability to care for herself.” She was able to answer multiple, simple questions appropriately and “showed she was competent.” “Everything matched up, there was no reason to believe that she couldn’t get on a bus and walk to her house.” She was “very forward thinking,” and worried about her cat and dog. The ED was not busy that day and he spent more time than usual with Patient E1. He wanted to make ensure she was fine. The cabs were not running that day, but the buses were. Security was driving people down to the bus stop. Patient #1 was discharged to the waiting room. She was there for about 15 minutes before security took her to the bus stop. If she had “given any red flags,” he “would have gotten everyone involved, and completed further assessments.” “She was as normal as you or I.” Sometimes EMS trip reports were not readily available when patients were in the ED. When he looked back after Patient #1 had been found deceased, he saw that the EMS trip report was timestamped for 45 minutes after she had been discharged. During an interview on 01/15/25 at 1:40 PM. Staff E, ED Charge RN, stated that she only saw Patient #1 when she arrived at the ED via EMS. Her clothing was appropriate for the weather. She had a jacket and maybe a beanie hat. She was calm and cooperative. Later, Staff T, ED RN, notified Staff E that Patient #1 was refusing care and wanted to get on the bus. The physician had seen the patient and she was ready for discharge. “Cabs were running very sporadically that day,” so family and the bus were primary transportation methods. It was not uncommon for EMS to report behaviors before arrival to the hospital and when the patients arrived at the ED, their behavior was completely different. During a telephone interview on 01/14/25 at 6:40 PM, Staff V, Security, stated that he was working on 01/05/25. It was snowing, and there were no taxis or cabs. The only transportation was by the bus system. He and his partner, Staff W, Security, were driving patients down to the bus stop since it was not close to the ED entrance. They picked up Patient #1 with two other females and dropped them off at the bus stop. On their next round, all three females were still at the bus stop, so they stopped to check on them. The next bus wasn’t due for another 30 minutes, they offered to take them to another bus stop by a gas station, just down the road. Two of the females went to the gas station bus stop. On their way back, they stopped and asked Patient #1 if she wanted to go back to triage and wait where it was warm. She said no and that she would wait. She had a coat and hat, but Staff V and Staff W, decided to go back to triage and get a warm blanket for her. When they offered it to her, she refused the warm blanket. Staff V was surprised that she did not want the warm blanket and that she did not want help. She looked okay, answered their questions appropriately, and said she had a house that she was going to. Staff V did not specifically see anything off, there was “no confusion, nothing out of the ordinary. She seemed normal in the moment.” Security then went and picked up another patient and transported him to the bus stop. Staff V and Staff W “were going to stick around and wait but were due to rotate back inside” and another security team took over outside patrols. During an interview on 01/14/25 at 6:00 PM, Staff W, Security, stated, on 01/05/25, he and another Security staff member had been assigned to drive patients to the bus stop as they were discharged from the ED. It was very cold, with blizzard like conditions. They transported Patient #1 and two other women to the bus stop after they were discharged from the ED. When they returned to the bus stop on another round, the three women were still there at the bus stop. Two of the women explained that they needed to go to the gas station to catch the right bus. Patient #1 insisted on staying at the hospital bus stop, she did not want to go to the gas station. She remained outside in the cold, so he decided to go back to the ED to get her a warm blanket. When he returned to the bus stop with the warm blanket, she refused to take it. He was worried about leaving her there and attempted to get her to go back up to the hospital to warm up. She refused, so he left her at the bus stop. He went back to the hospital to make another round and when he returned to drop off another person, he did not see her there. He assumed she had caught the bus. She had seemed a little irritated and was tired of waiting on the bus. He worked until 6:00 PM that evening. During an interview on 01/15/25 at 9:15 AM, Staff Y, Lead Ground Maintenance, stated that on 01/05/25, around 1:30 PM or 2:00 PM, he had been cleaning the parking lot at the professional building due to the blizzard like conditions. While in his vehicle, when he noticed someone outside the building. He thought it was a man in a coat, bundled up well. All he could make out was the face. It looked as if they were trying to look in the window, “almost trying to find a way in, their fingers were on the window, like scratching on the window.” The professional building doors are badge access only. He called security to let them know that someone was outside in the blizzard at the professional building. Security said that they were aware. There had been a combative male in the ED that had been taken to the bus stop, and that people liked to get up against the building to get out of the wind. Staff Y did not know who he talked to in security. “It was a hell of a day to be waiting on the bus,” and it “was not the day to blow somebody off.” He felt that “further steps should have been taken.” During a telephone interview on 01/15/25 at 9:30 AM, Staff Z, Security Weekend Dayshift Sergeant, stated that on 01/05/25 around 1:30 PM or 1:40 PM, he received a phone call from the Staff Y, Lead Ground Maintenance, regarding a gentleman looking in the windows at the Professional building. He told Staff Y that the person was probably standing there to get out of the wind. He “assumed that the person was waiting on the bus and didn’t think anything more of it.” The call “did not seem odd, there was nothing unusual.” Security was driving people down to the bus stop and the gas station that day. On 01/06/25, at approximately 7:30 AM, three security officers were taking approximately nine individuals from triage to the bus stop. A staff member on the 10th floor called and reported a person in front of the building. Nobody realized that the person, Patient #1, was in a spot where it wasn’t easy for her to be seen. Staff Z indicated that the hospital “had guys everywhere that day.” The result was due to a “totality of circumstances.” During an interview on 01/15/25 at 10:25 AM, Staff CC, Cardiac PCU RN, stated that on 01/06/25 at approximately 7:40 AM, she was in Patient #30’s room, on the Cardiac PCU. Patient #30’s wife showed her that there was something outside the window. She couldn’t see the best, so she left the room and called security at approximately 7:43 AM. She told them that she didn’t know if it was a body or not, but asked them to send someone out to check. It was a “chaotic call,” with multiple people talking in the background. It “took him a few minutes to focus.” Security said that they would send someone out to check. Around 9:40 AM, she went into Patient #31’s room. Patient #31 was looking out the window and said, “that’s a body.” She looked out the window and saw the body. There were no footprints or tracks around the body. Staff CC called security and told them, “you have to go out there right now.” She was “very surprised” security had not gone out there earlier. She did not know who answered the phone when she called security, but a different person answered both times. Patient #30 and his wife didn’t mention seeing Patient #1 outside the night before. Patient #31 told Staff CC that she had spoken with Patient #30’s wife the night before about Patient #1 walking outside. Patient #31 also reported that someone was outside, to Staff HH, CNA, during the night. During an interview on 01/15/25 at 3:00 PM, Staff DD, Cardiac PCU Charge RN, stated that on 01/16/25, she was contacted by Staff CC, Cardiac PCU RN. She reported seeing something from Patient #31’s room. Patient #31 was concerned and had requested that she, Staff CC, come to her room to look. Staff DD looked out the window towards the building across the street. There appeared to be a figure laying on their side. She remembered thinking there were “no footprints around the body.” Staff CC had notified security around 7:30 AM and called them again, about ten minutes before calling Staff DD. Patient #31 mentioned she saw someone wandering over there during the night and had told a staff member on the previous shift about it. Staff DD contacted Staff X, Director of Clinical Operations, and notified her of the possible body. Staff DD observed security drive up, get out of the vehicle, and walk to the body. During an interview on 01/15/25 at 2:30 PM, Staff EE, Security Dayshift Sergeant, stated that on 01/06/25, he arrived at the hospital around 8:06 AM. Around 9:30 or 9:40 AM, he was called by a nurse on the 10th floor, who said there was a body in the snow outside a hospital building. Staff D, Security Officer, had just returned to campus, so he asked him to go check it out, he notified the security captain. Staff EE received a call from Staff D indicating that the person was deceased. Staff EE contacted the police and Staff X, Director of Clinical Operations, and went to the scene. He would have expected the patient to be up by the main entrance doors to the Professional Building, not down in the dip next to the windows. The area where she was found was “a blind spot.” When he got there, the patient was frozen. EMS put leads on the patient and pronounced her dead. This was considered an unattended death, which made it a crime scene. Staff EE did not recall being told by Staff Z, Security Weekend Dayshift Sergeant, about a call prior to the call he received at 9:30 AM. If he had been notified, security staff “would have been at the scene immediately.” He might have had someone swing by and check on the patient if a call from the grounds crew came in. During an interview on 01/15/25 at 8:54 AM, Staff D, Security Officer, stated that on the morning of 01/06/25, between 6:00 AM and 9:30 AM, there were lots of homeless people in the ED waiting on warming shelters. Security staff took few of the homeless down to the cafeteria for boxed lunches. One of the homeless persons became upset due to not being allowed to eat in the cafeteria, they were being taken to another room to eat. Staff D could not recall if the security supervisor was present in the cafeteria during that incident. Staff D was only aware of one call to security, which was around 9:35 AM, when he was sent to check on the person. There were typically five to seven security staff on a shift, but that morning, they were short three people. Two security staff were late, but were there by 9:30 AM, and one was unable to come in. Around 9:35 AM, he had just arrived back on campus after giving a ride to an employee when he got a call on the radio that someone on one of the upper floors of the hospital had seen someone laying in the snow. When he pulled up, he could not see anything from the street or the bus stop. He parked near the entry into the Professional Building, and then saw a body lying in the snow. He called his supervisor, and then went down to the body. There were no visible signs of life. He tapped the body, but there was no response. He saw a hospital wristband on the body’s wrist. He notified his supervisor to call the Fire Department and Police Department. The supervisor came out to the scene. The police and EMS arrived and put leads on the patient to check for a heartbeat, but there were no signs of life. The police placed a blanket over the top of the patient, while hospital staff from plant operations brought a tent to place over the body. Administration was notified of the situation. Staff could notify security of issues in two ways. By calling their direct phone number or by calling the operator. The security supervisor received the calls and dispatched the officers, he does not respond to calls. During an interview on 01/15/25 at 8:25 AM, Staff X, Director of Clinical Operations, stated that she was doing her rounds on 01/06/25 when Staff DD, Charge RN, notified her, around 9:43 AM, that a patient and Staff CC, RN, had seen a possible body in the snow outside. Security had been called earlier that shift, but nothing had been done, so security was called again. Staff X radioed security, but there was no answer, so she assumed they were responding to the situation. She called the operator, who informed her that security had been dispatched. She went to the Professional Building and saw that police, fire, and EMS personnel were present. She walked to the railing, and down, tucked in the back was the body. Staff X talked with Staff EE, Security Dayshift Sergeant, and asked if they knew who the body was. Staff EE provided her with the name and date of birth that were listed on the hospital ID band upon the patient’s wrist. Staff X called a coworker to look up the information, which confirmed it was Patient #1. She remained on scene, spoke with the police officer and requested to be notified when the medical examiner arrived. She later looked up Patient #1’s record, which listed a sister, but no contact information. Staff X contacted Staff DD and instructed her to tell Staff CC thank you for the notification. Staff X was able to speak with Staff CC to ensure that the patient, who initially notified Staff CC about the body, was okay. Staff X was unaware that the patient had previously reported their concerns, regarding Patient #1, to hospital staff during the night of 01/05/25. During an interview on 01/15/25 at 10:05 AM, Staff BB, Cardiac PCU Director, stated she was not there on 01/06/25. She completed staff interviews via phone on 01/07/25. She spoke with Patient #31, who notified Staff CC, Cardiac PCU RN, about seeing Patient #1 outside. Patient #31 said she had notified a nurse the day before that someone was pacing outside. The Patient #30’s wife had looked out the window and observed something as well. Patient #31 reported that she had told Staff CC and two other staff members, Staff AA, Cardiac PCU RN, and Staff FF, Eighth Floor RN, about seeing someone outside. Staff BB contacted Staff AA and Staff FF, but they both denied being told by Patient #31 about a person walking around. Patient #31 was interviewed by police. Staff BB thought that the security director and a chaplain were present for the police interview. During a telephone interview on 01/15/25 at 9:55 AM, Staff AA, Cardiac PCU RN, stated that she was not told by Patient #31 that a person was walking around outside. Patient #31 never said anything to her about seeing anything or anyone. She was unaware of the incident until she saw it on the news. The weather that day was very bad. During a telephone interview on 01/15/25 at 3:30 PM, Staff FF, Eighth Floor RN, stated that she worked on 01/05/25 from 7:00 AM to 7:000 PM on the Cardiac PCU. Patient #31 did not tell her anything during her shift. During a telephone interview on 01/16/25 at 10:00 AM, Staff HH, CNA, stated that he worked the dayshift on 01/05/25 and had stayed late to help the nightshift. Around 11:00 PM or midnight, he was taking vital signs on patients, when Patient #31 mentioned seeing someone outside. He looked out the window, but only saw employees removing snow. When he returned to work the next morning, on 01/06/25, Patient #30’s wife asked if someone was lying on the ground. Staff HH asked Staff CC, Cardiac PCU RN, to come in and look. Staff CC entered the room, looked out the window, then called security. Patient #31 was “very with it,” and nothing would have made him question what she reported. During an interview on 01/15/25 at 11:00 SM, Staff A, COO, stated that Patient #31 was not interviewed by Hospital Administration or Management. Patient #1 was found with her pants down and law enforcement indicated it was a criminal investigation. During an interview on 01/15/25 at 11:05 AM, Staff II, Chief of Security, stated that during an active criminal investigation, the hospital would take a supportive stance and would not interfere with a police investigation. During an interview on 01/16/25 at 9:15 AM, Staff GG, Hospital Chaplain, stated that she was asked by the patient experience office to meet with Patient #31, since she had requested prayer. Patient #31 shared that she was overwhelmed and not sleeping well. Staff GG informed the unit director, that Patient #31 may need a list of therapists upon discharge. Staff BB, Cardiac PCU Director, and Staff II, Chief of Security, arrived with the police to interview Patient #31. She requested that Staff GG remain for the police interview. Patient #31 reported that she had watched a person wandering around outside for an hour or more. She indicated that she called and asked the nurse to send someone out to check on the person, but she never saw anyone go out. She went to sleep, and when she woke up, she looked out the window and saw the body. She immediately called someone in. During the police interview, Patient #31 did not indicate a specific time frame for when she observed Patient #1. She knew it was still snowing and it was around the time she was getting ready for bed that evening. Staff GG stated that Patient #31’s story did not change when she gave her statement to the police. During an interview on 01/15/25 at 10:25 AM, Staff II, Chief of Security, stated that Police Department E requested to interview Patient #31. Staff GG, Hospital Chaplain, was present for moral support at the patient’s request. It was a possible criminal investigation at that point. Patient #31 stated that she looked out the window and saw someone outside. She notified a nurse, with a Jamaican accent. The next morning, she woke up and saw someone lying in the snow and reported that to a nurse. Patient #31 was obviously upset during the interview with the police. Staff Z, Security Weekend Dayshift Sergeant, reported to Staff II that Staff Y, Lead Ground Maintenance, said there was a man outside the Professional Building. It was Staff II’s understanding that Staff Z did not dispatch anyone to the Professional Building. Security staff were actively transporting people to the bus stop and had multiple things going on. The sergeant prioritized calls as they came in. Staff II assumed that if someone required assistance, there would have been many opportunities for them to ask for help. Security staff were responsible for over 70 acres of hospital property. People waiting on the bus did not always wait at the bus stop. Security staff did not normally take people to the bus stop, but they were doing that due to the inclement weather. They were successfully assisting people to the bus stop and off campus, until Patient #1. “If someone is here, we need to make sure they get taken care of.” Patient #1 convinced multiple people that she was not in distress. Staff II reviewed the security video footage of Patient #1 in the ED and saw “zero indication that she needed medical attention.” She must have presented in a way, to the security officers, that she did not want help or require intervention. Generally, the security thought process was that if a patient was discharged, then they were of sound mind and ready to leave campus. During an interview on 01/15/25 at 1:55 PM, Staff G, ED Medical Director, stated that he was out of town when he received notification of the situation with Patient #1. Staff U, ED Physician, walked him through the visit and what he observed. Patient #1 was brought in from the casino, she felt like she did not need to be seen and wanted to go home. She seemed like she wanted to get back to her dog or cat. She did not want her family contacted and wanted to go home via bus. “People were not normally forced to go places,” so they needed to make sure she had the capacity to make decisions at that time. Staff U was very conscientious about his job. He asked the patient multiple times why she was at the casino. Patient #1 was very forward thinking, which was key. Forward thinking was planning for the future and having goals. This was part the thought process, and a protective factor that providers want to see. He reviewed Patient #1’s medical record and wished they “would have had better information from the police and EMS.” There were no affidavits in her medical record. Patient #1’s EMS trip report was not always available immediately. EMS had 24 hours to complete and save it in the hospital system. Based on record review, it seemed like “when she was here in the ED, she was clearer.” Staff G “did not see anything to hold her against her will.” When asked if a reasonable person would refuse a warm blanket, he stated that was “kind of a red flag.” He wished she would have taken the blanket or gotten on the bus. When asked at what point security should have intervened and brought the patient back to the ED, he stated that he did not know and he had “struggled with that question.” It was the least busy day in the ED for the 13 years Staff G had worked there. The ED was very well staffed and in no rush to get Patient #1 out. During a telephone interview on 01/21/25 at 9:05 AM, Staff JJ, Police Department D Officer, stated that on 01/06/25, he was driving down the interstate not far from the casino. He spotted a car off in a ditch. As he was driving over to the car, he received a call to check the area around the casino for Patient #1’s car. The car he observed “had gone off the road” and was “off in a field, nose down in a deep ditch.” The car was “fairly beat up” and Patient #1 would not have been able to “drive it from where it was.” He could not recall if the airbags had deployed, but there was no damage to the front end or any evidence of a front-end impact. The car was approximately 100 to 200 yards away from the casino, and approximately 50 yards away from the casino parking lot. The car’s position could not be seen from the casino or the parking lot due to a large fence. They “were lucky we found it where they did.” *Note: the information in this interview was unavailable to EMS, police, and ED staff until after Patient #1 was found deceased. During a telephone interview on 02/26/27 at 1:30 PM. Staff OO, Detective stated that he was assigned as the lead detective to investigate the death of Patient #1. The autopsy results were pending and this was an active criminal case until he received those results and made a determination. At the time of interview, he stated he did not suspect foul play. He had been able to review the video surveillance from the hospital. He was able to see security drop her off at the bus stop. A security vehicle came by the bus stop and loaded several people in their vehicle, but Patient #1 remained at the bus stop. A short time later, the security vehicle stopped by the bus stop and per interview with security, they offered her a blanket, but she declined. He was able to watch Patient #1 as she walked over to the area where she was found deceased. She paced that area for hours. He stated he saw someone that was clearing the parking lot of snow stop as she had walked up to the front of the building. The individual appeared to make a phone call and then continued with the snow removal. Patient #1 walked back down to the area where her body was found and continued to walk around that area. She then laid down on the ground, he could visualize her moving her arms and legs, rolling back forth. At one point she attempted to take her pants off. At approximately 11:00 PM all movement stopped. Per video, no one made contact with her until approximately 9:40 AM the next morning. He then saw security reach down to check for a pulse and tap the body with his foot. He stated that he had reviewed video footage of the interviews and that Patient #31 was very upset. Patient #31 had indicated that she had told a nurse, identified as a black female with an accent, that someone was down in the snow walking around several times the night before Patient #1’s body was found. The patient assumed the nurse called security and she went to bed. When she woke up the next morning to look out the window, she saw the body lying in the snow and notified her dayshift nurse. That was about 7:30 AM, but no one from the hospital checked on the body until after 9:30 AM. Staff OO had requested medical records from the hospital but the request had been denied due to Health Insurance Portability and Accountability Act (HIPAA, provides privacy standards and protects patients’ medical records against unauthorized access). Therefore, he was unable to identify the nurse that was notified of a person walking around outside in the cold on the night of 01/05/24. He stated, “It was a shame, there were multiple opportunities that were missed by nursing staff and security to help this woman out and they could have prevented her death.” Police frequently responded to calls at the hospital if there were safety concerns and they would have transported Patient #1 home, back to the emergency room or to a warming shelter if they had been notified. If Patient #1 had refused to go with an officer, they would have assessed the situation and forced her out of the cold weather. If she was confused, they would have taken her back to the emergency room to be evaluated. 47504”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 46856 Based on interview, record review and policy review, the hospital failed to follow their policy to ensure a safe discharge for one patient (#1) out of 31 Emergency Department (ED) records reviewed for patients that presented to the ED from 07/05/24 through 01/13/25. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 6,943. Findings included: Review of the hospital’s undated policy titled, “Security & Safety - Security Responsibilities,” showed Security staff should: - Patrol the facility, adjacent parking areas and premises; - Assist patients, visitors, and employees in reasonable requests for service or guidance; - Be alert for and document potentially hazardous situations or conditions on hospital premises and within the facilities; - Maintain vigilance for unsafe acts, events or situations; and - Assist with transfers to the hospital during inclement weather. Review of the hospital’s undated policy titled, “Security,” showed that the hospital’s Security staff provides protection for employees, patients and visitors. Security also monitors the hospital’s buildings, equipment, and supplies, and is alert to potentially hazardous situations or conditions. Security officers patrol the facilities, adjacent parking areas, and premises to assist employees, patients, and visitors. Security and safety are the responsibility of every NKCH staff member. For the welfare of patients, visitors and fellow employees, all staff should be alert to the presence of suspicious persons, particularly in unauthorized areas; suspicious activity of any nature; unusual findings or incidents; and circumstances which look out of place. The Security staff should be notified immediately in the event of such occurrences. Review of the hospital’s undated policy titled, “ED - Discharge of Patient from the Emergency Department,” showed that the ED follows the general guidelines for discharge of a patient from the hospital. Review of the hospital’s undated policy titled, “Discharge,” showed that a discharge plan is developed based on individual needs and discussed with the patient and/or caregiver. The nurse will review discharge instructions with the patient. Any patient requiring transportation from the hospital must have documentation from case management and/or the Director of Clinical Operations. Discharge considerations for winter weather included a winter storm warning (heavy snow of six inches in 12 hours or eight inches in 24 hours, or sleet of one-half inch or more) and/or a blizzard warning (blizzard conditions for at least three hours). Review of Police Department D’s report, titled “Offense/Incident Report,” dated 01/05/25, related to Patient #1, showed that Staff LL, Corporal for Police Department D, was dispatched on 01/05/25 at approximately 11:11 AM to a casino regarding a female who was trespassing. Upon arrival, he was contacted by security who advised that the female claimed to work there, was trying to access employee only areas, she seemed confused and believed the casino was Costco. Staff LL contacted the female (Patient #1). She was very abrasive and refused to answer questions. She did state that she thought it was 2024, Friday, that she was in Kansas City, and that the casino was or used to be a Costco. Patient #1 appeared to be suffering from some form of mental health issue that limited her ability to answer questions correctly or to know where she was. Patient #1 was clearly in a delusional state of mind. EMS was requested for Patient #1 due to her failure to answer questions in conjunction with the winter storm which limited her ability to go anywhere safely. Patient #1 persistently refused to answer questions and was physically forced onto the stretcher for transportation to the hospital. Staff used a firm grip when assisting her onto the stretcher. She was clearly upset but appeared to understand the need to cooperate with Fire Department B. She was transferred to NKCH without any other incidents. It was unclear as to how she came to be at the casino. She claimed to have driven, but due to the winter storm, it seemed unlikely. Review of Fire Department C’s EMS record, related to Patient #1, dated 01/05/25, showed that EMS was dispatched to the casino for a patient with an altered mental status (mental functioning ranging from slight confusion to coma). Multiple Police Department D units were on scene prior to EMS arrival. Patient #1 was found standing upright in the exit atrium area of the casino. She presented as alert and oriented to self only. She was able to speak and answer some questions appropriately. Police Department D told EMS that the patient had been there for approximately six hours and was disoriented to where she was. She repeatedly told police that she thought the casino was a “Costco” and that her house was at the casino. She refused to answer any orientation questions or allow EMS to obtain any vital signs (VS, measurements of the body’s most basic functions). She continued being uncooperative, despite many attempts by EMS and law enforcement attempts to initiate care. Casino security told the police that they did not want her on the property. This was relayed to the patient, she was informed that if she did not accept care, she could be arrested. Fire Department B EMS arrived on scene and her care was transferred to their staff. The attending medic was given a summary of the patient’s complaints, findings, and treatments. Patient #1 continued to be uncooperative. Eventually, a decision was made to place her in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and to transport her to the hospital due to her altered mental status. Police Department D was able to maneuver her to the stretcher. Once she was on the stretcher, she calmed down and no restraints were needed. Her physical assessment indicated no abnormal findings. Her Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 14. The EMS primary impression was excited (agitated) delirium (an abrupt change in the brain that causes confusion). Patient #1 was transported by Fire Department B EMS to NKCH. Review of Fire Department B’s EMS record, related to Patient #1, dated 01/05/28, showed that EMS was dispatched to the casino along with Fire Department C and Police Department D for a reported behavioral health issue. The patient was confused/disoriented and not wanting to cooperate with Fire, EMS, or Police. Casino security reported making contact with Patient #1 at approximately 6:00 AM. She was observed via a security camera attempting to go into restricted areas of the casino, cleaning the restroom, and reporting to security that she was an employee. Upon arrival, Patient #1 was found to be walking on scene, agitated, anxious, angry/upset, not making any sense, and her thought process was all over the place. She was alert and talking but did not want to answer any questions for EMS. Her physical assessment showed no abnormal physical findings. Her VS were within normal limits. Her GCS was 14. She was mentally unstable, and Police Department D staff had to physically assist her on to the stretcher. She did not want to be transported and reported that she was perfectly fine. Once she was placed on the stretcher, she was secured, monitored and transported to NKCH. Review of Patient #1’s ED record, dated 01/05/25, showed the following: - She was a 63-year-old female with no past medical history listed. Her sister was listed as an emergency contact, but there was no working telephone number listed. - The pre-arrival report sheet noted that Patient #1 was found wandering around the casino, was angry, and her vital signs were stable. - Bedside report indicated that she had been walking outside and had no complaints. There was no medical history, allergies, medications and/or drug or alcohol use listed. - Neither the pre-arrival nor the bedside report indicated that Patient #1 was confused. - On 01/05/25 at 12:23 PM, she was brought in via EMS after being found walking around the casino. - At 12:27 PM, Staff T, ED RN, documented that Patient #1 was found wandering around the casino, was kicked out, and became angry. She had no complaints at that time and denied SI and HI. Her temperature was slightly elevated at 99.5 degrees along with her blood pressure of 158/98. She denied any pain. Her C-SSRS score was zero and her GCS was 15. - At 12:39 PM, Staff U, ED Physician, documented that Patient #1 had no medical complaints. She was upset she was there. She was somewhat confused and would not give him a definitive reason why she was at the casino that morning. It was not clear how she got to the casino or why she went there in the first place. She was alert and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). She knew she was at the hospital, she told Staff U her address which matched the one listed on her driver’s license. She did leave the house that morning, and she lived at home with her dog and cat. She did not want to have anything done in the ED and requested that they help her get home. Her speech was normal, her movements were coordinated, and her cognition appeared normal. Her VS were within normal limits. She was able to answer all of Staff U’s other questions appropriately. Documentation indicated that Staff U did not believe that the hospital had the right to hold her down and/or force medical care on her. This included laboratory testing and obtaining a urinalysis (a laboratory examination of a person’s urine). She did not appear to be under the influence of any drugs or alcohol, she exhibited no acute hallucinations, delusions, or psychosis (mental illness characterized by defective or lost contact with reality). - At 1:05 PM, Staff T, ED RN, documented that Patient #1 was discharged to home. Her BP was slightly elevated at 159/91, her GCS was 15 and she denied any pain. - Her total length of stay in the ED was 42 minutes. Review of Patient #1’s EMS record from Fire Department B showed that EMS was dispatched on 01/05/25. Upon arrival to the casino, Fire Department C and Police Department D reported some type of behavioral health issue going on because the patient was confused/disoriented and not wanting to cooperate with Fire, EMS, or Police. Casino security reported making contact with the patient at approximately 6:00 AM because she was seen through a security camera attempting to go into restricted areas of the casino, cleaning the restroom, and reporting to security that she was an employee. Upon arrival, the patient was found to be walking on scene, agitated, anxious, angry/upset, not making any sense, her thought process was all over the place. She was alert, talking and did not want to answer any questions for EMS. Her physical assessment showed no abnormal physical findings. Her vital signs were within normal limits. Her GCS was 14. She was mentally unstable, and Police Department D had to force her on to the cot, because she did not want to be transported and reported that she was perfectly fine. She was placed on the cot, secured, monitored and transported to NKCH. Review of the hospital’s event report titled, “Current Summary,” dated 01/07/25, showed that on 01/06/25 at 7:40 AM, Staff CC, Cardiac Progressive Care Unit (PCU, a telemetry [remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring) RN, was alerted by the wife of Patient #30 to a questionable object outside of Patient #30’s window. Staff CC saw what appeared to be a long dark object, but visibility was low. Staff CC notified security and asked them to check on the suspicious object. She explained to security that the shape resembled a body and it looked out of place. Security indicated that they would send someone to check. Two hours later, Staff CC entered into Patient #31’s room to pass medications and perform an assessment. Patient #31 was standing by the window and looking out. She asked Staff CC what she thought was on the ground. The light was better at that time. Staff CC looked out and clearly saw a body lying on their right side in the snow. The body did not move. Staff CC called security again, at 9:45 AM. She informed them that she had called earlier, but no one had checked on the situation. There were no tracks in the snow and the object was clearly a body. The security guard stated that they would send someone to check. Review of the hospital’s security report titled, “Incident Report,” dated 01/07/25 at 11:45 AM, showed on 01/06/25 at approximately 9:39 AM, Staff D, Security Officer, was dispatched to the Professional Building for a reported person down. Staff CC, Cardiac PCU RN, reported observing, from the 10th floor Cardiac PCU, what she believed was a person lying in the snow. Upon his arrival, Staff D noticed a person lying on the ground near the electrical boxes below the handicap parking, near the building. The person appeared to be without signs of life. He called out to the individual without response and tapped her on the shoulder. She felt cold to the touch and solid as if rigor mortis (stiffening of the joints and muscles of the body a few hours after death) had set in. Staff D notified Staff EE, Security Dayshift Sergeant, of the situation and requested that EMS and Police Department E be called. EMS responded and found no vital signs and no signs of life. Staff EE notified Staff X, Director of Clinical Operations, and the Security Supervisor. Staff D remained at the scene until Police Department E arrived. The medical examiner removed Patient #1’s body at approximately 12:45 PM. Staff Y, Lead Ground Maintenance, stated he observed Patient #1 near the main entrance appearing to attempt to get into the building on 01/05/25 at approximately 2:50 PM. Security video review showed Patient #1 coming out of triage with a nurse. Patient #1 entered security’s vehicle and was dropped off at the bus stop located on the hospital’s campus. Several buses had come and gone. When security dropped off another discharged patient at the bus stop, they appeared to check on Patient #1, that was between 1:06 PM and 1:45 PM. At 1:47 PM, Patient #1 walked down to the area near the Professional Building, where she was later found. At 1:50 PM, Patient #1 appeared to attempt to enter the main entrance of the Professional Building. At 1:52 PM, she walked back down to the area near the Professional Building. Between 1:52 PM and 9:16 PM, Patient #1 paced back and forth around the Professional Building near the electrical boxes. From 9:16 PM to 11:15 PM, Patient #1 lay on the ground moving. At 11:15 PM, Patient #1 moved for the last time. It was noted that Patient #1 was outside in what appeared to be heavy snow and blizzard like conditions. A supplemental report, dated 01/06/25 at 5:00 PM, Staff EE, Security Dayshift Sergeant, was instructed by the Security Supervisor to return to the scene of the incident to attempt to locate Patient #1’s purse. He located a grate that was ajar on the south side of the Professional Building. He looked down the shaft, below the grate and discovered a purse at 5:17 PM. Staff EE retrieved the purse. Two IDs were also found in the pit. A Plant Operations employee used a small ladder to retrieve them. On 01/07/25 at 11:02 AM, Staff II, Chief of Security, and a detective from Police Department E arrived at the security office, where the detective took possession of the purse. Review of Police Department D’s report, titled “Offense/Incident Report,” dated 01/06/25, showed that at 4:27 PM, Staff JJ, Police Department D Officer, was traveling northbound on Missouri Highway 69 crossing the Missouri River when he observed a dark vehicle in the ditch off Tremont Trafficway. While in route to check on the vehicle, he was notified by communications that Police Department E was requesting an area check of the casino for a vehicle. He advised communications that the vehicle he noted and was traveling to partially matched the provided description. Upon arrival, he confirmed the vehicle description and that the license plate matched the description of the vehicle that Police Department E had provided. The front end of the vehicle was in a ditch, with only the rear of the vehicle sticking up. At the request of his sergeant, he looked through the vehicle’s windows for Patient #1’s purse and cellular telephone. He did not see anything matching the provided description and he did not open the vehicle. He contacted a tow company and the vehicle was transported to a storage facility. Review of Police Department E’s report titled, “Offense/Incident Report,” dated 01/06/23, showed the following: - Staff EE, Security Dayshift Sergeant, contacted the police department regarding a potential deceased individual. Multiple police officers responded to the scene while Fire Department B checked for signs of life. At 9:54 AM, Patient #1 was pronounced deceased. The initial responding Police Officer stated that Staff D, Security Officer, was advised by a staff nurse that there was a body lying in the snow outside. The body was found lying in the snow, on the east side of 2700 Clay Edwards Drive, south of the retaining wall. Staff D nudged the body with his foot and realized she was stiff to touch. He notified his supervisor. The time of the notification was not noted in the report. There appeared to be no obvious signs of trauma. Patient #1 had a medical bracelet on from North Kansas City Hospital that was dated 01/05/25. From 01/05/25 into 01/06/25, there were freezing temperatures and blizzard like conditions. The police officer was advised by Staff EE that Patient #1 had been brought to the hospital at approximately 12:23 PM on 01/05/25, by EMS from a local casino. She had been discharged on 01/05/25 at 1:05 PM. - Staff OO, Detective, arrived on the scene to initiate an investigation. He notified Patient #1’s sister of her death. During their interview, Patient #1’s sister stated that Patient #1 worked at Costco. Her normal working hours were 4:30 AM to 2:00 PM. She had been employed at Costco for approximately 20 years. Patient #1 did not gamble and it was “odd” that she was at the casino. Patient #1 had been previously diagnosed with a form of dementia (a loss of thinking abilities and memory). - Staff OO contacted Police Department D for additional information. Patient #1 had been found by casino security wandering around and attempting to get into restricted areas. She was combative and refused to leave, so security called the police. Dispatch stated that Police Department D had been dispatched to the casino at 11:11 AM and that Fire Department B had been dispatched at 12:00 PM. Patient #1 was transported for altered mental status to North Kansas City Hospital by Fire Department B. Staff OO reviewed the body camera footage of the officers that responded to the casino, which showed that Patient #1 was confused as to where she was and thought she was at Costco. Her vehicle was found off the roadway in a ditch about three to four blocks from the casino. - Staff OO, contacted Costco, Patient #1’s place of employment. Management acknowledged that Patient #1 had some memory issues. At times, she did not know where she was while at work, failed to clock in or out, and at times did not know what she was doing at work. - On 01/06/25 at 5:45 PM, Staff OO was notified that Patient #1’s purse was found, 25 yards away from where her body had been located, sitting on a grate. The contents of the purse had spilled down into the area beneath the grate. - On 01/07/25 at 9:00 AM, an interview was conducted with Staff CC, Cardiac PCU RN. She stated that Patient #30’s wife had asked her to look out the window to identify an object. It was dark outside, but she saw a rectangular object in the grass. She notified security regarding the object at 7:43 AM. A couple of hours later, the sun was up, and she could clearly see that the object was a body lying in the grass. She notified security again at 9:43 AM. She did not observe anyone near the body. - On 01/07/25 at 10:45 AM, Staff OO reviewed the video of Patient #1’s movements while on hospital property. Security provided a ride for Patient #1 and several other patients, to the bus stop around 1:00 PM. A short time later, when a bus arrived, she did not get on the bus. Patient #1 remained at the bus stop with several other people. Security returned and according to interview, Patient #1 failed to accept a ride to a gas station down the road, where another bus stop was located. Security transported some of the others in their vehicle and Patient #1remained standing at the bus stop alone. A short time later, security returned to the bus stop and was offered a blanket, but she declined. Patient #1 remained at the bus stop. She eventually made her way to the area where she was later found deceased. She was observed walking around that small area for the remainder of the day. She did approach the front doors of the 2700 building and was observed communicating with a person within a snow removal vehicle. Patient #1 then walked back down to the area where she was found, wandering around until 11:00 PM. At approximately 9:00 PM, Patient #1 laid down on the ground, where she was later found. She was observed lying on the ground, moving her arms and legs. rolling from side to side. She did not get up from that position and stopped moving at approximately 11:00 PM. - On 01/07/25 at 12:28 PM, an interview was conducted with Patient #31. Patient #31’s room was the last one on the hall, with two windows facing 2700 Clay Edwards Drive. She reported that on 01/05/25 at approximately 9:30 PM, she observed someone walking around in the snow outside of 2700 Clay Edwards Drive building. She informed her nurse, described as a black female with an accent, that someone was walking around in the cold weather. She stated the nurse notified security regarding the individual. When Patient #31 awoke on 01/06/25 at approximately 6:10 AM, she observed what appeared to be a body lying on the ground. She then notified Staff CC of the body. She also spoke with Patient #30’s wife who also observed the body lying on the ground. She did not observe security in the area, where the body was found, until approximately 9:40 AM. Security had been notified multiple times that someone was walking around in the cold and that Patient #1’s body was lying in the snow. Review of the hospital’s document titled, “North Kansas City Hospital Emergency Department Activity Log,” from 01/04/25 to 01/06/25, showed the following: - On 01/04/25, there were a total of 175 patients seen in the ED. - On 01/05/25, there were a total of 68 patients seen in the ED. - On 01/06/25, there were a total of 168 patients seen in the ED. Review of the hospital’s document titled, “Security Dispatch Log,” from 01/03/25 to 01/07/25, showed no documentation of any phone calls to security, on 01/05/25 or 01/06/25, regarding Patient #1. Review of the hospital’s document titled, “Security and Safety Shift Summary,” dated 01/06/25, showed on 01/05/25, from 1:05 PM to 2:10 PM, security staff transported multiple individuals to the bus stop on the hospital’s campus and the bus stop at a nearby gas station. There was no documentation of any phone calls regarding Patient #1 wandering outside the Professional Building. Review of the hospital’s document titled, “Security and Safety Shift Summary,” dated 01/07/25, showed on 01/06/25, from 7:42 AM to 8:50 AM, nine homeless discharged patients were escorted from the triage area to the cafeteria, then transported to the bus stop. At 9:41 AM, a call was received regarding a downed person. At 5:00 PM, the Security Supervisor initiated a property search. The property was located and secured. There was no documentation of any phone calls to security regarding Patient #1 lying in the snow, outside the Professional Building. Review of the National Weather Service almanac for Kansas City, Missouri, showed that on 01/05/25, the lowest temperature was 12° F, with the highest temperature of 22° F, wind chills as low as 15 below zero, and 11 inches of snowfall. Observation on 01/15/24 at 11:20 AM, from the 10th floor PCU window, showed a view of the 2700 Clay Edwards Drive building and the bus stop down the street. There were handicap parking spaces to the left of the entrance of the building, then a retaining wall and railing. Below the retaining wall was a flat area, in front of a row of windows, with an electrical transformer near the building. An additional wall blocked the view from the road. Per Staff A, Chief Operating Officer (COO), Patient #1 was found behind the additional wall, near the electrical transformer. Observation on 01/15/25 at 11:40 AM, at the bus stop where Patient #1 was dropped off, showed a significant distance between the bus stop and where Patient #1’s body was found. A State Surveyor and Staff A, COO, stood approximately where Patient #1’s body was found, near the electrical transformer, while another State Surveyor and Staff B, Vice President of Quality, stood at the bus stop. When looking from the bus stop toward where Patient #1’s body was found, it was very difficult to see the State Surveyor and Staff A, standing next to the electrical transformer, due to the distance, terrain and snowfall. From the bus stop, it was impossible to see anything on the ground next to the State Surveyor and Staff A, due to the terrain and snowfall. During a telephone interview on 01/22/25, Staff LL, Corporal for Police Department D, stated that on 01/05/25, he was called to the casino. The casino manager reported that Patient #1 was trying to get into secured areas, claimed that she worked there, and then thought she was at Costco. Patient #1 was not an employee at the casino. He spoke with Patient #1, and she was “obviously confused and not well oriented.” Patient #1 did not want to fully identify herself or to provide any family phone numbers. She “got every mental health question wrong.” She had no obvious trauma or injuries. She was dressed appropriately for walking out to the car, but not appropriately dressed for being outside for a long period of time. Patient #1 “was not capable of making her own decisions.” She thought Staff LL “was harassing her at her house,” and “seemed very confused” about who Staff LL was. Staff LL was unable to locate Patient #1’s car in the casino parking lot. He thought “something’s wrong here,” and called EMS for a mental health assessment. EMS arrived and assessed the patient. She did not want EMS to do anything and refused to let them take her blood pressure or check her blood glucose. He was told by EMS that if Patient #1 couldn’t answer four basic questions, they would have to take her to the hospital. Staff LL and the EMS crew observed the same symptoms that Patient #1 was exhibiting. She was escorted to the stretcher, and he removed Patient #1’s ID from her purse. He located a phone number for the patient’s son. Staff LL then called and left Patient #1’s son a message. Staff LL stated that the police “only fill out affidavits if patients are suicidal or a harm to themselves or others for a 96-hour hold.” During a telephone interview on 01/23/25, Staff MM, Fire Department C Lieutenant and Paramedic, stated that Police Department D requested EMS to the casino. Patient #1 could talk; she was confused and thought the casino was Costco. Later, Patient #1 thought that she was in her house. She was dressed in jeans and a jacket, which was weather appropriate. She “was definitely confused, but somewhat with it.” She started to walk out of the casino, made it about five yards out the door, then was redirected by Staff MM, who was able to convince her to return inside. Fire Department C did not have an ambulance, so Fire Department B was contacted to send an ambulance. Staff MM and the police officers tried to get Patient #1 to go to the hospital, but she was not cooperating. It “got to the point” where Staff MM asked the police officers if Patient #1 was going to be arrested for trespassing since she was uncooperative. After that, Patient #1 was guided onto the stretcher. Staff MM stated that he did not normally fill out affidavits, they were usually completed by law enforcement. During a telephone interview on 02/26/25 at 11:55 AM, Staff NN, Fire Department B Firefighter and Paramedic, stated that he was dispatched to the casino where Fire Department C and Police Department D were already on scene. When he arrived, Police Department D officers were arguing with the patient at one of the casino entrances. Patient #1 “was not making any sense, and her thought process was all over the place.” She was saying “erratic” stuff. She kept saying that they had been to her home numerous times, she kept repeating herself and would not answer questions. Casino staff reported that she had been “roaming the casino since 6:00 AM that morning,” trying to clean the restrooms and to access restricted areas. Patient #1 was not employed at the casino. There were red flags that “she was not there.” She was arguing and did not want to go to the hospital. Staff NN requested Police Department D officers to assist her to the stretcher. Once on the stretcher, she was transported to North Kansas City Hospital. While in route, she remained uncooperative. Staff NN “was not able to get a straight answer” from her. He provided a radio report to the ED and informed the nurse about Patient #1’s abnormal behaviors. When they arrived at the ED, they transferred the patient to a hospital bed and he provided a bedside report to the nurse which detailed her abnormal behaviors. Patient #1 continued to exhibit the same symptoms during the bedside report that she was exhibiting at the casino. There were no affidavits completed regarding Patient #1. Staff NN stated that if a patient constantly fought and did not want to be transported to the hospital, he would have the police officers complete an affidavit or have them respond to the ED with the patient. During an interview on 01/14/25 at 3:20 PM, Staff T, ED RN, stated that she was the nurse for Patient #1. Patient #1 arrived at the ED via EMS. She was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), appropriate and cooperative, but irritable. She was placed directly in an exam room within the ED. She received report from EMS, which was “short and simple.” EMS reported that they were called to the casino because casino security staff felt that Patient #1 had “erratic” behavior. She had refused to answer casino security’s questions and EMS staff felt that she was “altered.” Upon arrival to the ED, EMS told Staff T that Patient #1 had calmed down for them and felt that she “would be calm for her.” Staff T received most of the history from the patient. She asked Patient #1 why she was at the ED. Patient #1 told her that she was not sure why she was there and wanted to go home. Patient #1 reported no past medical history, had not ever been seen at the hospital and had no emergency contacts listed. The triage form included several behavioral health questions, including SI and whether or not the patient had a safe home environment. Patient #1 denied SI and was “very offended when she was asked those questions.” Staff T assumed that Patient #1 quit answering questions for the first responders prior to her arrival at the ED because she was irritated with them. Staff T was not present for Staff U’s, ED Physician, assessment. After Staff U completed his assessment, they compared notes. Patient #1 knew her home address, reported no complaints and wanted to go home. Staff U said that Patient #1 was appropriate for discharge and that they could not hold her. Staff U completed discharge orders and Staff T provided the discharge instructions to Patient #1. Some patients would be sent home via cab when discharged, if they did not have any family to transport them. That day, due to the inclement weather, the only options for transportation after discharge were patients’ family members or the bus system. Patient #1 indicated that she wanted to ride the bus home, her son was working and she did not want to call him. Staff T tried multiple times to get the patient to call her family to come pick her up, but she “was adamant about riding the bus home.” Patient #1 said she knew it was snowing, but she had cats at home that she needed to feed. Staff T reviewed the bus times and identified that the next bus would arrive at 1:11 PM. Staff T walked Patient #1 out to the waiting room. Security was to drive Patient #1 to the bus stop, which was down around the corner from the ED. Staff T stated that at the time of Patient #1’s ED visit, she was unaware that she had access to the EMS trip reports. She did not review EMS trip reports as part of her usual work process. She has since been educated on how to access trip tickets by management. During an interview on 01/14/25 at 3:50 PM, Staff U, ED Physician, stated that Patient #1 was brought in by EMS. By the time he assessed Patient #1, EMS had already left. The report sheet indicated she was agitated. Staff T, ED RN, reported to him that Patient #1 had become agitated, there was an altercation with casino staff, and she was told to leave. Patient #1 had never been seen at the hospital prior to this visit. There were no next of kin or contact information listed. Patient #1 told Staff U that she was poorly treated by casino staff. She was upset, and it took a while for her to calm down and to start answering questions. Patient #1 told him that she got up that morning and drove to the casino, parked in the north lot and it was snowing. Staff U asked Patient #1 why she was at the casino, but she did not seem to want to answer that. She said casino security told her to leave and she argued with them. Patient #1 allowed Staff U to do a physical exam. She answered the orientation questions appropriately, was able to state her address (which he confirmed by looking at her driver’s license) and informed him that she worked at Costco. Her vital signs were good, though her heart rate was slightly fast. Her neurological (neuro, relating to or affecting the nervous system) exam was normal, and there were no concerning physical findings. Staff U asked her if there was anyone he could call for her, and she reported that she lived alone. Staff U asked Patient #1 how she was going to get home, and she said she would take the bus home, it went right by her house. She was adamant about leaving. He was not aware of any psychiatric or behavioral problems. There was no indication for any laboratory testing or a urinalysis. She showed no signs of infection, “no red flags to be concerned about regarding mental instability or an inability to care for herself.” She was able to answer multiple, simple questions appropriately and “showed she was competent.” “Everything matched up, there was no reason to believe that she couldn’t get on a bus and walk to her house.” She was “very forward thinking,” and worried about her cat and dog. The ED was not busy that day and he spent more time than usual with Patient E1. He wanted to make ensure she was fine. The cabs were not running that day, but the buses were. Security was driving people down to the bus stop. Patient #1 was discharged to the waiting room. She was there for about 15 minutes before security took her to the bus stop. If she had “given any red flags,” he “would have gotten everyone involved, and completed further assessments.” “She was as normal as you or I.” Sometimes EMS trip reports were not readily available when patients were in the ED. When he looked back after Patient #1 had been found deceased, he saw that the EMS trip report was timestamped for 45 minutes after she had been discharged. During an interview on 01/15/25 at 1:40 PM. Staff E, ED Charge RN, stated that she only saw Patient #1 when she arrived at the ED via EMS. Her clothing was appropriate for the weather. She had a jacket and maybe a beanie hat. She was calm and cooperative. Later, Staff T, ED RN, notified Staff E that Patient #1 was refusing care and wanted to get on the bus. The physician had seen the patient and she was ready for discharge. “Cabs were running very sporadically that day,” so family and the bus were primary transportation methods. It was not uncommon for EMS to report behaviors before arrival to the hospital and when the patients arrived at the ED, their behavior was completely different. During a telephone interview on 01/14/25 at 6:40 PM, Staff V, Security, stated that he was working on 01/05/25. It was snowing, and there were no taxis or cabs. The only transportation was by the bus system. He and his partner, Staff W, Security, were driving patients down to the bus stop since it was not close to the ED entrance. They picked up Patient #1 with two other females and dropped them off at the bus stop. On their next round, all three females were still at the bus stop, so they stopped to check on them. The next bus wasn’t due for another 30 minutes, they offered to take them to another bus stop by a gas station, just down the road. Two of the females went to the gas station bus stop. On their way back, they stopped and asked Patient #1 if she wanted to go back to triage and wait where it was warm. She said no and that she would wait. She had a coat and hat, but Staff V and Staff W, decided to go back to triage and get a warm blanket for her. When they offered it to her, she refused the warm blanket. Staff V was surprised that she did not want the warm blanket and that she did not want help. She looked okay, answered their questions appropriately, and said she had a house that she was going to. Staff V did not specifically see anything off, there was “no confusion, nothing out of the ordinary. She seemed normal in the moment.” Security then went and picked up another patient and transported him to the bus stop. Staff V and Staff W “were going to stick around and wait but were due to rotate back inside” and another security team took over outside patrols. During an interview on 01/14/25 at 6:00 PM, Staff W, Security, stated, on 01/05/25, he and another Security staff member had been assigned to drive patients to the bus stop as they were discharged from the ED. It was very cold, with blizzard like conditions. They transported Patient #1 and two other women to the bus stop after they were discharged from the ED. When they returned to the bus stop on another round, the three women were still there at the bus stop. Two of the women explained that they needed to go to the gas station to catch the right bus. Patient #1 insisted on staying at the hospital bus stop, she did not want to go to the gas station. She remained outside in the cold, so he decided to go back to the ED to get her a warm blanket. When he returned to the bus stop with the warm blanket, she refused to take it. He was worried about leaving her there and attempted to get her to go back up to the hospital to warm up. She refused, so he left her at the bus stop. He went back to the hospital to make another round and when he returned to drop off another person, he did not see her there. He assumed she had caught the bus. She had seemed a little irritated and was tired of waiting on the bus. He worked until 6:00 PM that evening. During an interview on 01/15/25 at 9:15 AM, Staff Y, Lead Ground Maintenance, stated that on 01/05/25, around 1:30 PM or 2:00 PM, he had been cleaning the parking lot at the professional building due to the blizzard like conditions. While in his vehicle, when he noticed someone outside the building. He thought it was a man in a coat, bundled up well. All he could make out was the face. It looked as if they were trying to look in the window, “almost trying to find a way in, their fingers were on the window, like scratching on the window.” The professional building doors are badge access only. He called security to let them know that someone was outside in the blizzard at the professional building. Security said that they were aware. There had been a combative male in the ED that had been taken to the bus stop, and that people liked to get up against the building to get out of the wind. Staff Y did not know who he talked to in security. “It was a hell of a day to be waiting on the bus,” and it “was not the day to blow somebody off.” He felt that “further steps should have been taken.” During a telephone interview on 01/15/25 at 9:30 AM, Staff Z, Security Weekend Dayshift Sergeant, stated that on 01/05/25 around 1:30 PM or 1:40 PM, he received a phone call from the Staff Y, Lead Ground Maintenance, regarding a gentleman looking in the windows at the Professional building. He told Staff Y that the person was probably standing there to get out of the wind. He “assumed that the person was waiting on the bus and didn’t think anything more of it.” The call “did not seem odd, there was nothing unusual.” Security was driving people down to the bus stop and the gas station that day. On 01/06/25, at approximately 7:30 AM, three security officers were taking approximately nine individuals from triage to the bus stop. A staff member on the 10th floor called and reported a person in front of the building. Nobody realized that the person, Patient #1, was in a spot where it wasn’t easy for her to be seen. Staff Z indicated that the hospital “had guys everywhere that day.” The result was due to a “totality of circumstances.” During an interview on 01/15/25 at 10:25 AM, Staff CC, Cardiac PCU RN, stated that on 01/06/25 at approximately 7:40 AM, she was in Patient #30’s room, on the Cardiac PCU. Patient #30’s wife showed her that there was something outside the window. She couldn’t see the best, so she left the room and called security at approximately 7:43 AM. She told them that she didn’t know if it was a body or not, but asked them to send someone out to check. It was a “chaotic call,” with multiple people talking in the background. It “took him a few minutes to focus.” Security said that they would send someone out to check. Around 9:40 AM, she went into Patient #31’s room. Patient #31 was looking out the window and said, “that’s a body.” She looked out the window and saw the body. There were no footprints or tracks around the body. Staff CC called security and told them, “you have to go out there right now.” She was “very surprised” security had not gone out there earlier. She did not know who answered the phone when she called security, but a different person answered both times. Patient #30 and his wife didn’t mention seeing Patient #1 outside the night before. Patient #31 told Staff CC that she had spoken with Patient #30’s wife the night before about Patient #1 walking outside. Patient #31 also reported that someone was outside, to Staff HH, CNA, during the night. During an interview on 01/15/25 at 3:00 PM, Staff DD, Cardiac PCU Charge RN, stated that on 01/16/25, she was contacted by Staff CC, Cardiac PCU RN. She reported seeing something from Patient #31’s room. Patient #31 was concerned and had requested that she, Staff CC, come to her room to look. Staff DD looked out the window towards the building across the street. There appeared to be a figure laying on their side. She remembered thinking there were “no footprints around the body.” Staff CC had notified security around 7:30 AM and called them again, about ten minutes before calling Staff DD. Patient #31 mentioned she saw someone wandering over there during the night and had told a staff member on the previous shift about it. Staff DD contacted Staff X, Director of Clinical Operations, and notified her of the possible body. Staff DD observed security drive up, get out of the vehicle, and walk to the body. During an interview on 01/15/25 at 2:30 PM, Staff EE, Security Dayshift Sergeant, stated that on 01/06/25, he arrived at the hospital around 8:06 AM. Around 9:30 or 9:40 AM, he was called by a nurse on the 10th floor, who said there was a body in the snow outside a hospital building. Staff D, Security Officer, had just returned to campus, so he asked him to go check it out, he notified the security captain. Staff EE received a call from Staff D indicating that the person was deceased. Staff EE contacted the police and Staff X, Director of Clinical Operations, and went to the scene. He would have expected the patient to be up by the main entrance doors to the Professional Building, not down in the dip next to the windows. The area where she was found was “a blind spot.” When he got there, the patient was frozen. EMS put leads on the patient and pronounced her dead. This was considered an unattended death, which made it a crime scene. Staff EE did not recall being told by Staff Z, Security Weekend Dayshift Sergeant, about a call prior to the call he received at 9:30 AM. If he had been notified, security staff “would have been at the scene immediately.” He might have had someone swing by and check on the patient if a call from the grounds crew came in. During an interview on 01/15/25 at 8:54 AM, Staff D, Security Officer, stated that on the morning of 01/06/25, between 6:00 AM and 9:30 AM, there were lots of homeless people in the ED waiting on warming shelters. Security staff took few of the homeless down to the cafeteria for boxed lunches. One of the homeless persons became upset due to not being allowed to eat in the cafeteria, they were being taken to another room to eat. Staff D could not recall if the security supervisor was present in the cafeteria during that incident. Staff D was only aware of one call to security, which was around 9:35 AM, when he was sent to check on the person. There were typically five to seven security staff on a shift, but that morning, they were short three people. Two security staff were late, but were there by 9:30 AM, and one was unable to come in. Around 9:35 AM, he had just arrived back on campus after giving a ride to an employee when he got a call on the radio that someone on one of the upper floors of the hospital had seen someone laying in the snow. When he pulled up, he could not see anything from the street or the bus stop. He parked near the entry into the Professional Building, and then saw a body lying in the snow. He called his supervisor, and then went down to the body. There were no visible signs of life. He tapped the body, but there was no response. He saw a hospital wristband on the body’s wrist. He notified his supervisor to call the Fire Department and Police Department. The supervisor came out to the scene. The police and EMS arrived and put leads on the patient to check for a heartbeat, but there were no signs of life. The police placed a blanket over the top of the patient, while hospital staff from plant operations brought a tent to place over the body. Administration was notified of the situation. Staff could notify security of issues in two ways. By calling their direct phone number or by calling the operator. The security supervisor received the calls and dispatched the officers, he does not respond to calls. During an interview on 01/15/25 at 8:25 AM, Staff X, Director of Clinical Operations, stated that she was doing her rounds on 01/06/25 when Staff DD, Charge RN, notified her, around 9:43 AM, that a patient and Staff CC, RN, had seen a possible body in the snow outside. Security had been called earlier that shift, but nothing had been done, so security was called again. Staff X radioed security, but there was no answer, so she assumed they were responding to the situation. She called the operator, who informed her that security had been dispatched. She went to the Professional Building and saw that police, fire, and EMS personnel were present. She walked to the railing, and down, tucked in the back was the body. Staff X talked with Staff EE, Security Dayshift Sergeant, and asked if they knew who the body was. Staff EE provided her with the name and date of birth that were listed on the hospital ID band upon the patient’s wrist. Staff X called a coworker to look up the information, which confirmed it was Patient #1. She remained on scene, spoke with the police officer and requested to be notified when the medical examiner arrived. She later looked up Patient #1’s record, which listed a sister, but no contact information. Staff X contacted Staff DD and instructed her to tell Staff CC thank you for the notification. Staff X was able to speak with Staff CC to ensure that the patient, who initially notified Staff CC about the body, was okay. Staff X was unaware that the patient had previously reported their concerns, regarding Patient #1, to hospital staff during the night of 01/05/25. During an interview on 01/15/25 at 10:05 AM, Staff BB, Cardiac PCU Director, stated she was not there on 01/06/25. She completed staff interviews via phone on 01/07/25. She spoke with Patient #31, who notified Staff CC, Cardiac PCU RN, about seeing Patient #1 outside. Patient #31 said she had notified a nurse the day before that someone was pacing outside. The Patient #30’s wife had looked out the window and observed something as well. Patient #31 reported that she had told Staff CC and two other staff members, Staff AA, Cardiac PCU RN, and Staff FF, Eighth Floor RN, about seeing someone outside. Staff BB contacted Staff AA and Staff FF, but they both denied being told by Patient #31 about a person walking around. Patient #31 was interviewed by police. Staff BB thought that the security director and a chaplain were present for the police interview. During a telephone interview on 01/15/25 at 9:55 AM, Staff AA, Cardiac PCU RN, stated that she was not told by Patient #31 that a person was walking around outside. Patient #31 never said anything to her about seeing anything or anyone. She was unaware of the incident until she saw it on the news. The weather that day was very bad. During a telephone interview on 01/15/25 at 3:30 PM, Staff FF, Eighth Floor RN, stated that she worked on 01/05/25 from 7:00 AM to 7:000 PM on the Cardiac PCU. Patient #31 did not tell her anything during her shift. During a telephone interview on 01/16/25 at 10:00 AM, Staff HH, CNA, stated that he worked the dayshift on 01/05/25 and had stayed late to help the nightshift. Around 11:00 PM or midnight, he was taking vital signs on patients, when Patient #31 mentioned seeing someone outside. He looked out the window, but only saw employees removing snow. When he returned to work the next morning, on 01/06/25, Patient #30’s wife asked if someone was lying on the ground. Staff HH asked Staff CC, Cardiac PCU RN, to come in and look. Staff CC entered the room, looked out the window, then called security. Patient #31 was “very with it,” and nothing would have made him question what she reported. During an interview on 01/15/25 at 11:00 SM, Staff A, COO, stated that Patient #31 was not interviewed by Hospital Administration or Management. Patient #1 was found with her pants down and law enforcement indicated it was a criminal investigation. During an interview on 01/15/25 at 11:05 AM, Staff II, Chief of Security, stated that during an active criminal investigation, the hospital would take a supportive stance and would not interfere with a police investigation. During an interview on 01/16/25 at 9:15 AM, Staff GG, Hospital Chaplain, stated that she was asked by the patient experience office to meet with Patient #31, since she had requested prayer. Patient #31 shared that she was overwhelmed and not sleeping well. Staff GG informed the unit director, that Patient #31 may need a list of therapists upon discharge. Staff BB, Cardiac PCU Director, and Staff II, Chief of Security, arrived with the police to interview Patient #31. She requested that Staff GG remain for the police interview. Patient #31 reported that she had watched a person wandering around outside for an hour or more. She indicated that she called and asked the nurse to send someone out to check on the person, but she never saw anyone go out. She went to sleep, and when she woke up, she looked out the window and saw the body. She immediately called someone in. During the police interview, Patient #31 did not indicate a specific time frame for when she observed Patient #1. She knew it was still snowing and it was around the time she was getting ready for bed that evening. Staff GG stated that Patient #31’s story did not change when she gave her statement to the police. During an interview on 01/15/25 at 10:25 AM, Staff II, Chief of Security, stated that Police Department E requested to interview Patient #31. Staff GG, Hospital Chaplain, was present for moral support at the patient’s request. It was a possible criminal investigation at that point. Patient #31 stated that she looked out the window and saw someone outside. She notified a nurse, with a Jamaican accent. The next morning, she woke up and saw someone lying in the snow and reported that to a nurse. Patient #31 was obviously upset during the interview with the police. Staff Z, Security Weekend Dayshift Sergeant, reported to Staff II that Staff Y, Lead Ground Maintenance, said there was a man outside the Professional Building. It was Staff II’s understanding that Staff Z did not dispatch anyone to the Professional Building. Security staff were actively transporting people to the bus stop and had multiple things going on. The sergeant prioritized calls as they came in. Staff II assumed that if someone required assistance, there would have been many opportunities for them to ask for help. Security staff were responsible for over 70 acres of hospital property. People waiting on the bus did not always wait at the bus stop. Security staff did not normally take people to the bus stop, but they were doing that due to the inclement weather. They were successfully assisting people to the bus stop and off campus, until Patient #1. “If someone is here, we need to make sure they get taken care of.” Patient #1 convinced multiple people that she was not in distress. Staff II reviewed the security video footage of Patient #1 in the ED and saw “zero indication that she needed medical attention.” She must have presented in a way, to the security officers, that she did not want help or require intervention. Generally, the security thought process was that if a patient was discharged, then they were of sound mind and ready to leave campus. During an interview on 01/15/25 at 1:55 PM, Staff G, ED Medical Director, stated that he was out of town when he received notification of the situation with Patient #1. Staff U, ED Physician, walked him through the visit and what he observed. Patient #1 was brought in from the casino, she felt like she did not need to be seen and wanted to go home. She seemed like she wanted to get back to her dog or cat. She did not want her family contacted and wanted to go home via bus. “People were not normally forced to go places,” so they needed to make sure she had the capacity to make decisions at that time. Staff U was very conscientious about his job. He asked the patient multiple times why she was at the casino. Patient #1 was very forward thinking, which was key. Forward thinking was planning for the future and having goals. This was part the thought process, and a protective factor that providers want to see. He reviewed Patient #1’s medical record and wished they “would have had better information from the police and EMS.” There were no affidavits in her medical record. Patient #1’s EMS trip report was not always available immediately. EMS had 24 hours to complete and save it in the hospital system. Based on record review, it seemed like “when she was here in the ED, she was clearer.” Staff G “did not see anything to hold her against her will.” When asked if a reasonable person would refuse a warm blanket, he stated that was “kind of a red flag.” He wished she would have taken the blanket or gotten on the bus. When asked at what point security should have intervened and brought the patient back to the ED, he stated that he did not know and he had “struggled with that question.” It was the least busy day in the ED for the 13 years Staff G had worked there. The ED was very well staffed and in no rush to get Patient #1 out. During a telephone interview on 01/21/25 at 9:05 AM, Staff JJ, Police Department D Officer, stated that on 01/06/25, he was driving down the interstate not far from the casino. He spotted a car off in a ditch. As he was driving over to the car, he received a call to check the area around the casino for Patient #1’s car. The car he observed “had gone off the road” and was “off in a field, nose down in a deep ditch.” The car was “fairly beat up” and Patient #1 would not have been able to “drive it from where it was.” He could not recall if the airbags had deployed, but there was no damage to the front end or any evidence of a front-end impact. The car was approximately 100 to 200 yards away from the casino, and approximately 50 yards away from the casino parking lot. The car’s position could not be seen from the casino or the parking lot due to a large fence. They “were lucky we found it where they did.” *Note: the information in this interview was unavailable to EMS, police, and ED staff until after Patient #1 was found deceased. During a telephone interview on 02/26/27 at 1:30 PM. Staff OO, Detective stated that he was assigned as the lead detective to investigate the death of Patient #1. The autopsy results were pending and this was an active criminal case until he received those results and made a determination. At the time of interview, he stated he did not suspect foul play. He had been able to review the video surveillance from the hospital. He was able to see security drop her off at the bus stop. A security vehicle came by the bus stop and loaded several people in their vehicle, but Patient #1 remained at the bus stop. A short time later, the security vehicle stopped by the bus stop and per interview with security, they offered her a blanket, but she declined. He was able to watch Patient #1 as she walked over to the area where she was found deceased. She paced that area for hours. He stated he saw someone that was clearing the parking lot of snow stop as she had walked up to the front of the building. The individual appeared to make a phone call and then continued with the snow removal. Patient #1 walked back down to the area where her body was found and continued to walk around that area. She then laid down on the ground, he could visualize her moving her arms and legs, rolling back forth. At one point she attempted to take her pants off. At approximately 11:00 PM all movement stopped. Per video, no one made contact with her until approximately 9:40 AM the next morning. He then saw security reach down to check for a pulse and tap the body with his foot. He stated that he had reviewed video footage of the interviews and that Patient #31 was very upset. Patient #31 had indicated that she had told a nurse, identified as a black female with an accent, that someone was down in the snow walking around several times the night before Patient #1’s body was found. The patient assumed the nurse called security and she went to bed. When she woke up the next morning to look out the window, she saw the body lying in the snow and notified her dayshift nurse. That was about 7:30 AM, but no one from the hospital checked on the body until after 9:30 AM. Staff OO had requested medical records from the hospital but the request had been denied due to Health Insurance Portability and Accountability Act (HIPAA, provides privacy standards and protects patients’ medical records against unauthorized access). Therefore, he was unable to identify the nurse that was notified of a person walking around outside in the cold on the night of 01/05/24. He stated, “It was a shame, there were multiple opportunities that were missed by nursing staff and security to help this woman out and they could have prevented her death.” Police frequently responded to calls at the hospital if there were safety concerns and they would have transported Patient #1 home, back to the emergency room or to a warming shelter if they had been notified. If Patient #1 had refused to go with an officer, they would have assessed the situation and forced her out of the cold weather. If she was confused, they would have taken her back to the emergency room to be evaluated.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41865 Based on interview, record review and policy review, the hospital failed to ensure the safety of all behavior health patients when they failed to provide a contraband free and psychiatric (relating to mental illness) safe patient environment for one discharged patient (Patient #5) of one patient reviewed. (A-0144) The hospital also failed to ensure that restraint orders were renewed in a timely manner for three current patients (#1, #45, and #48) out of six records reviewed. (A-0168) These failures had the potential to place all patients admitted to the hospital at risk for their safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation (CoP): Patient’s Rights. The hospital census was 230.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39354 Based on interview, record review and policy review, the hospital failed to ensure the safety of all behavior health patients when they failed to provide a contraband free and psychiatric (relating to mental illness) safe patient environment for one patient (Patient #5) that was located in a monitored, psychiatric safe ED room. They failed to ensure that staff monitored the patient at all times; and there were no keys left in a tele-psych cart when it was taken in the patient’s room. Review of the hospital’s undated policy titled, “Care of the Suicidal/Homicidal/Unsafe Patient”, showed patients who screen with a high suicide risk will trigger immediate notification for the physician and/or a behavioral health consult. The patient will be placed under direct observation and staff will initiate the “NKCH (North Kansas City Hospital) suicidal, homicidal, and unsafe patient care guidelines”. Review of the hospital’s undated document titled, “NKCH Suicidal, Homicidal, and Unsafe Patient Care Guidelines,” directed staff to: - Prepare the ED room for appropriate patient safety by removing items which could cause danger to the patient or others. - Assign the patient to an inpatient room close to the nurse’s station and away from stairs and elevators. - Maintain constant visual contact of the patient, observing them for any potentially harmful behaviors and to never leave them alone. - Monitor items coming in/out of the room for any dangerous items. Although requested the hospital was unable to provide video recordings of ED room 13, room 16, the nurse’s station or the hallway. Review of Patient #5’s medical record dated 07/08/24 through 07/09/24 showed: - She was a 38-year-old female, who presented to the ED having suicidal ideations (SI, thoughts of causing one’s own death) and had self-harmed by cutting her wrist. - Her recent history included multiple attempts at cutting her wrist to end her life. She required surgical intervention for a recent attempt. She reported intrusive thoughts, where she “feels like a robot” and would attempt to cut her wrist. She did not have persistent intent or a plan but would have significant periods of intrusive thoughts. Prior to her ED visit, she had thought about cutting her wrist with a knife. Her wife intervened. There was a small amount of bleeding on her wrist where she had been picking at the surgical wound. - Staff CC, Physician, documented that she had a “mild controlled wound to the left wrist, no evidence of arterial bleed or injury to her radial/ulnar artery.” A small amount of skin glue was placed on the wound. A behavioral health consult was ordered. - At 12:50 AM, a Nurse’s Note showed that Patient #5 had a one-centimeter (cm) laceration (a deep cut or tear in skin) to the left wrist. The patient reported the laceration was old but that she had been picking it open. The bleeding was controlled. The patient reported having no plan other than cutting her wrist and had no SI at that time. - At 2:44 AM, a Tele-psychiatry note showed the patient had a history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock).She presented to the ED for intermittent intrusive thoughts to kill herself by cutting her wrists for the past two weeks. One episode required surgical intervention. On the evening of 07/08/24, the patient tried to cut her wrist with a knife, but her wife intervened. She had been picking at a previous wound. She presented to the hospital because she broke open a razor, removed the blade, and attempted to re-cut her wrist. While in the ED she admitted to trying to reopen the glued wound with her thumb. - At 4:30 AM, a dressing was applied to the patient’s left wrist. - At 7:00 AM, the patient’s family was at the bedside. - At 7:43 AM, Staff FF, RN, documented she was informed that the patient had taken the tele-psych cart keys off the cart during the tele-psych assessment around 2:40 AM. The patient gave the keys to her sister, who then informed Staff C, MHT. When asked why she had taken them, the patient stated, “they were shiny and when I see shiny things, I take them to cut myself.” The patient stated, “shiny things” make her impulsive and caused intrusive thoughts to self-harm. She denied any specific trigger. Her left wrist and dressing were assessed, they remained clean, dry, and intact. Staff FF completed a sweep of the patient’s room to locate any other objects that the patient could use to harm herself with. She ensured all her personal belongings were locked in a cabinet within the patient’s room. - At 1:08 PM, the patient was admitted to the hospital due to lack of psychiatric bed availability. - On 07/09/24 at 3:00 PM, the patient was transferred to an inpatient psychiatric hospital. During an interview on 08/07/24 at 12:50 PM, Staff QQ, BHA, stated that BHAs were not required to stay in the room with patient’s during the tele-psych consultations. She took the cart into the patient’s room but did not notice if the cart had any keys on it. She stated, “she did not look down,” and “only checked that the screen and the volume were working.” During an interview on 08/07/24 at 11:00 AM, Staff NN, MHT, stated that she was responsible for watching the patient during the night shift on 07/08/24. During her shift, the patient’s sister reported to her that the patient had reopened the wound on her wrist. She immediately reported that to the patient’s nurse. Staff NN was not aware of the patient having any keys until her supervisor reached out to her the next day. The patient’s sister never mentioned any keys to her, and she did not see the patient with any keys. During an interview on 08/07/24 at 7:30 AM, Staff EE, RN, stated the physician ordered the patient’s wrist wound to be glued and have a dressing placed. There was not a lot of blood, and she did not remember how the wound had opened. The patient did not have any keys. During an interview on 08/06/24 at 1:00 PM, Staff CC, Physician, stated that Patient #5 came to the ED due to SI and that prior to her arrival she had been picking at an old wound on her left wrist. While in the ED, the patient continued to pick at her wrist, so it was covered with glue to provide a protective barrier and to maintain integrity of the skin. It was not gapping open, it was a small opening, there was not a lot of blood. To his knowledge the patient did not harm herself with anything she obtained from the hospital. During an interview on 08/07/24 at 1:02 PM, Staff C, MHT, stated that she was responsible for supervising the patient during the dayshift of 07/08/24. The patient’s sister came up to her shortly after her shift started and gave her a key. She asked the patient’s sister where she got it from, and she said the patient gave it to her. She said the patient got it from the tele-psych cart that was left in the room and the that she had been hiding it. She went to the patient’s room, removed the cart and took the key to a BHA. The key was bent but she did not remember there being any blood on the key. During an interview on 08/07/24 at 9:00 AM, Staff FF, RN, stated that she took over Patient #5’s care at 7:00 AM, on 07/08/24, and the patient was asleep. Shortly after, it was reported to her, by Staff C, that the patient’s sister brought her a key and told her that the patient had been hiding it. The patient’s sister said a tele-psych cart was brought in for a consult in the middle of the night, there were keys on the cart, and no one was watching the patient, so she took the keys and started picking at her scabs under the blankets before her wound was cleaned and bandaged. The patient’s sister said the patient got bored so she put the keys underneath her body and went to sleep. Staff FF immediately went to assess the patient. There was a very minimal amount of dried blood on the patient’s blanket. When she checked the patient’s wound, the wound was bandaged, and the bandage was dry and intact. Nothing had been disturbed on the bandage. She never saw any evidence of the wound being picked at. During an interview on 08/07/24 at 12:30 PM, Staff RR, Charge RN, stated that the patient’s family member told Staff C, MHT, that the patient had attempted to re-open her wound with a pair of keys that she found in the room. After being notified of the incident she assessed the patient’s wrist. It had a bandage wrap on it, and she removed the wrap to assess the wound. The wound had a glue dressing that was still intact, and was not bleeding. The patient’s bed sheets had a smear mark of dried blood that was approximately five inches long by 1/8 inch wide. She completed an event report, and the department directors were notified.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50151 A-0168 Based on interview, record review and policy review the hospital failed to ensure the physician renewal orders for restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were written daily for three current patients (#1, #45 and #48) of six restraint patients reviewed. These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. Findings included: Review of the hospital’s non-dated policy, “Restraint Usage,” showed an order for Non-Violent/ Non-Self-Destructive restraints must be renewed daily for each instance a patient’s condition required restraints. Review of Patient #1’s medical record showed: - On 07/28/24 at 4:30 PM, while in the neuro-trauma intensive care unit (NTICU, an intensive care unit devoted to the care of patient with immediately life-threatening nervous system problems and traumatic injuries) an initial restraint order was placed for non-violent soft bilateral upper extremity (BUE) restraints. - On 07/30/24, there were no restraint orders. - Nursing documentation showed that Patient #1 was in restraints on 07/30/24, with no order for restraints. - On 07/31/24 at 7:00 PM, a renewal order was placed for non-violent BUE restraints. Review of Patient #45’s medical record showed: - 07/24/24 at 7:32 AM, while in the cardiac intensive care unit (CICU, an intensive care unit devoted to the care of patients with immediately life-threating cardiac problems) an initial restraint order was placed for non-violent soft BUE restraints. - On 07/27/24, there were no restraint orders. - Nursing documentation showed that Patient #45 was in restraints on 07/27/24, with no order for restraints. - On 07/28/24 at 6:15 PM, a renewal order for non-violent BUE restraints, was placed. Review of Patient #48’s medical record showed: - On 07/24/24 at 11:16 PM, while in the cardiovascular intensive care unit (CVICU, an intensive care unit devoted to the care of patient’s recovery from heart surgery) an initial order was placed for non-violent BUE restraints. - On 07/25/24, there were no restraint orders. - Nursing documentation showed that Patient #48 was in restraints on 07/25/24, with no order for restraints. - On 07/26/24 at 7:41 AM, a renewal order for non-violent BUE restraints, was placed. - On 07/26/24 at 11:00 PM, a second renewal order for non-violent BUE restraints was placed. - On 07/27/24, there were no restraint orders. - Nursing documentation showed Patient #48 was in restraints on 07/27/24, with no order for restraints. - On 07/28/24 at 7:00 PM, a renewal order for non-violent BUE restraints, was placed. - On 08/05/24, a renewal order for non-violent restraints, was not placed. - Nursing documentation showed Patient #48 was in restraints on 08/05/24, with no order for restraints. - On 08/06/24 at 11:00 PM, a renewal order for non-violent BUE restraints, was placed. On 08/05/24 at 3:00 PM, Staff F, Charge Nurse, stated that renewal restraint orders would be renewed every calendar day. Nurses receive a reminder to contact the physician so a renewal order can be placed. She confirmed that on 07/30/24, Patient #1 did not have a daily non-violent restraint order placed. During an interview on 08/07/24 at 3:15 PM, Staff O, Senior Nursing Director, stated that an order for non-violent restraints must be renewed each calendar day. It was the responsibility of the physician to renew restraint orders every calendar day. Nursing would receive a task notification to notify the physician when restraint orders need renewed.”