Based on observation, staff interview, document and video footage review, the Emergency Department (ED) Staff failed to provide an appropriate and ongoing medical screening exam (MSE) to 1 of 20 sampled patients (patient #1) presenting to the ED in the last six months from December 2015 to May 2016. The ED staff failed to complete an appropriate medical screening exam by not fully appreciating the patient's presentation and failed to protect his safety even though the ED staff was aware the patient had a history of dementia and had been identified as a flight risk (a person who is likely to flee). The patient eloped (walk away) from the ED and crossed busy streets with an IV (device used to access a blood vessel to deliver medications and/or fluids) still in place. Failure to provide an appropriate medical screening exam and allowing patients to elope from the ED places patients at risk for harm and/or death. Findings include: - The hospital's policy for EMTALA reviewed on 5/18/2016 at 8:30 AM directed, "...the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. A Medical Screening Examination is not an isolated event. It is ongoing process that may begin, but typically does not end with triage..." See further evidence at 2406

Based on observation, staff interview, document and video footage review, the Emergency Department (ED) Staff failed to provide an appropriate and ongoing medical screening exam (MSE) to 1 of 20 sampled patients (patient #1) presenting to the ED in the last six months from December 2015 to May 2016. The ED staff failed to protect patient # 1 even though the ED staff were aware the patient had presented with a history of dementia (gradual decrease of memory lost) and had been identified as a flight risk (a person who is likely to flee). The patient eloped (walk away) from the ED and crossed busy streets with an IV (device used to access a blood vessel to deliver medications and/or fluids) still in place. Failure to provide an appropriate medical screening exam and allowing patients to elope from the ED places patients at risk for harm and/or death. Findings include: Skilled Nursing Facility (SNF) Administrator BB interviewed by phone on 5/18/2016 at 9:40 AM indicated they arranged to transfer patient #1 to Shawnee Mission Medical Center (SMMC) at approximately 6:10 PM on 5/9/16 because he had a low hemoglobin. The SNF Charge nurse faxed patient #1's health information to SMMC. SNF Administrator BB stated that patient # 1's family member called the SNF at 8:10 PM and told the nurse in charge that patient #1 was at their house. The SNF called SMMC to verify that patient #1 was not at their hospital. Review of the Ambulance run report revealed an ambulance was requested to transport Patient #1 to SMMC on 5/9/2016 at 5:30 PM. The ambulance personnel documented patient #1 had a diagnosis of Alzheimer's (a progressive disease that destroys memory and other mental functions) and had become increasingly agitated and difficult to manager over the past few days. The ambulance personnel performed an EKG (a test used to measure the hearts rhythm) and inserted an intravenous (IV) catheter to access blood for testing and to administer IV fluids. Patient # 1 arrived at the SMMC emergency department (ED) at 6:35 PM and Paramedic EE gave report to ED nurse B. Review of the ED medical record revealed patient # 1 presented to the ED at SMMC at 6:35 PM. ED nurse B obtained patient # 1's vital signs and Physician F examined the patient and noted the patient's history of dementia and low hemoglobin (oxygen carrying capacity of the blood). At 6:46 PM blood for testing was collected and plans for placement in an observation bed were initiated. The medical record did not contain documentation on patient #1's care and treatment from 6:39 PM until 9:22 PM. The hospital Medical Surgical floor log sheet revealed patient #1 arrived back at the hospital and was taken directly to an observation bed on the medical / surgical floor at 9:47 PM on 5/9/16. Patient # 1 was assigned a sitter for the remainder of his stay at the hospital. Review of SMMC ' s Video surveillance showed the following: 6:35 PM on 5/9/16, Patient #1 arrived via ambulance through the ambulance entrance attached to the ED. Patient # 1 had an IV (device used to access a blood vessel to allow medication and/or fluid administration) with a bag of fluid attached to the IV line going to the patient. 7:07 PM- Patient #1 left ED room 9 wearing a red coat and walking past the information administration desk, the nursing station, and past the ambulance entrance. 7:10 PM- Patient #1 walked past the locked triage rooms, the triage desk at the main ED entrance, and continued walking down the hallway. 7:11 PM- 7:17PM - Patient #1 walked to a main lobby and was standing near two courtesy phones (unable to determine if patient used the telephone). 7:17 PM - Patient #1 walked out of the hospital and onto 74th street. 7:18 PM- 7:23 PM- Patient #1 was no longer in view of hospital cameras. 7:23 PM- 7:24 PM- Patient #1 was observed walking down the sidewalk near the life dynamics parking lot at the corner of 75th St and Kessler. The patient then walked across the four-lane street. 7:25 PM- Patient #1 no longer in camera views. ED nurse B interviewed on 5/16/16 at 3:00 PM indicated patient #1 presented to the ED with ambulance personnel and was told that the patient was a flight risk and to keep eye on him. ED nurse B stated that Patient #1 seemed a little agitated but tucked the patient in bed before leaving the patient's room. ED nurse B said that patient # 1 stated he did not need to be at the hospital, that he had a low hemoglobin for some time. ED nurse B reported to ED nurse E when changing shifts, that patient #1 was a flight risk and suggested to get a gown on patient #1. No family was with patient #1 but the patient mentioned their significant other would be coming. Medical Director C interviewed on 5/17/2016 at 9:25 AM indicated the hospital does not have a badge to place on a patient if they are a flight risk, and "does not have a policy as far as I know." Medical Director C indicated patients usually are placed in a gown as soon as possible. Medical Director C stated the hospital has enough sitters to provide to our patients if indicated. ED nurse E interviewed on 5/17/16 at 2:00 PM indicated ED nurse B gave a verbal report about patient # 1 as the shift was ending. ED nurse B reported that patient #1 was alert and oriented, with a monitor on and that he was a flight risk. ED nurse E left the ED to transfer another patient to the floor. ED nurse E estimated s/he was out of the ED for 20 minutes. As ED nurse E passed Patient #1's room s/he noticed the patient was gone. ED nurse E immediately notified Charge Nurse G, and called security. "Staff H and I started to look around everywhere and security arrived and we nurses gave the description of Patient #1 and what he was wearing." "While this was all happening, Patient #1's Skilled Nursing Facility called telling us family member AA got a call from a neighbor and that Patient #1 was at their house." Eventually patient #1 was brought back to the hospital. Physician F interviewed on 5/17/2016 at 3:00 PM indicated s/he remembers patient #1 came from a dementia unit in Paola, Kansas and was a flight risk. " Flight risk was put on our board. " "We first were planning to put patient # 1 in a locked unit due to the flight risk but the patient needed to be monitored." "Patient # 1 was placed in a room closest to the front desk. " Physician F remembers verifying patient #1's labs, placing orders to admit him and had closed patient #1's chart. ED nurse E notified physician F that patient #1 could not be found and security was called. Charge Nurse G notified the police. Physician F mentioned that ED nurse E spoke to a family member on the phone shortly after the patient was found at their house and were planning to have patient come back to the hospital. Physician F did not think of reopening the chart to document since s/he had already closed it. ED Charge Nurse G interviewed on 5/17/2016 at 3:30 PM indicated that ED nurse E notified them that patient #1 left the hospital and security was notified. Charge nurse G was told patient #1 had come to the hospital by EMS from a nursing home and that ED nurse E said that patient #1 was alert and oriented, had been known to just leave, and was a flight risk. This did not raise a red flag that the patient needed a sitter. Charge nurse G instructed ED nurse E to notify the police department and to fill out an incident report. We did not know if patient #1 took a taxi, left with family or who took him. ED nurse H interviewed at 5/17/2016 at 3:50 PM mentioned EMS gave report to ED nurse B. Patient #1came from a skilled nursing facility. EMS reported that patient #1 wanders at times. ED nurse B and H got patient #1 undressed and placed into a gown. ED nurse H wondered if they should keep patient #1's belongings in his room. ED nurse H said patient #1 was really with it, alert and oriented to time, place and person. ED nurse H was told by ED nurse E that they were going to take another patient up to the floor and would be right back. ED nurse H stated they checked on patient #1 and he did not want to watch TV so nurse H closed the door per the patient's request. When nurse E came back to the ED they asked nurse H where their patient went, patient #1's clothes were gone and the patient's gown was on the bed. Nurse H said that patient #1 did not seem confused, they were alert and oriented to time, place and person. House Supervisor I interviewed on 5/18/2016 at 8:00 AM indicated they were told by the ED Charge nurse, G, that patient #1 had eloped from the ED. Supervisor I was told patient #1 had dementia and a low hemoglobin. Supervisor I stated s/he was not informed that patient #1was a flight risk. House Supervisor J interviewed on 5/18/2016 at 8:00 AM indicated they came on shift at 11:00 PM and received report that the ED had a patient eloped. Patient #1 was found and came back to the hospital. Supervisor J did respond to the patient's room on a rapid response while patient #1 was receiving a blood transfusion. Afterwards, patient #1 was transferred to the Critical Care Unit. Director of Emergency Services A interviewed on 5/16/16 and 5/19/2016 at 11:00 AM indicated they were not aware patient #1 had left their facility the evening of 5/9/2016. The nurse or charge nurse of their department is to report any incidents in the electronic "Risk Master." Any "Risk Master" reports go directly to Director A. Director A stated they usually only receives calls at home if a situation is critical, otherwise the Charge Nurse and House Supervisors are responsible.

The hospital reported a census of 264 patients Based on observation, staff interview, and document review the hospital failed to meet the emergency medical needs for one of seven patients (Patient #1) that presented to the hospital for emergency medical treatment. Findings include: - Document titled "Performance Improvement Plan, 2015" reviewed on 12/14/15 directed " ...The Medical Staff is responsible to the Board of Trustees for effectively and efficiently delivering patient care according to established and accepted standards of care ..." - Patient #1's medical record reviewed on 12/1/2015 revealed the patient arrived to the hospitals ED (Emergency Department) on 2/25/15 at 11:59am after complications occurred during a scheduled eye surgery. Patient #1 arrived via ambulance after being extubated (removal of a breathing tube) at the surgical center. The medical record indicated the patient's intial vital signs were Heart rate (HR) 89, Respiratory rate (RR) 34, Oxygen saturation (O2) 90% with non-invasive ventilations (bag valve mask device used to force oxygen into the lungs), and Blood pressure (BP) 132/76. The Arterial Blood Gas (ABG) lab that was performed at the hospital, provided to the surgical center prior to transfer, and available to the ED physician revealed a PH of 7.14, CO2 70, BE -5, PO2 65 (drawn at surgery center at 11:02am) on 100% FIO2. The patient was placed on 15liters/per minute (lpm) of oxygen using a facemask and ABG labs were redrawn and resulted at 12:27pm and recorded as follows; a PH of 7.28, CO2 50, BE -3, PO2 57. Staff C, the ED physician, consulted Staff E at 12:41pm. Patient #1 was reportedly more awake and had complaints of dyspnea (short of air) at 2:01pm. Patient #1's ABG's were again obtained, PH of 7.314, CO2 47, BE -2, PO2 91 on 21% FI02, and resulted at 2:16pm. At 4:25pm the patient had a sudden decompensation in respiratory status, tachypnea and hypoxic, patient feeling like he is unable to breath, respirations were in the 40's with O2 sat 90% on 15 liters using a non-rebreather mask. The medical record revealed RT Staff E was called at 4:25pm and he placed the order for intubation. At 4:28pm Staff C performed endotracheal intubation to patient. The patient was transported at 6:00 pm by cart to the ICU with wife by his side. The medical record revealed the patient was intubated (a tube placed into the airway to assist breathing) ABG's resulting at 4:44pm revealed a PH of 7.16, CO2 60.1, BE -7, PO2 61 on 100% FI02 using an adult vent. The medical revealed at 11:43pm the patient went into cardio-respiratory arrest, a code blue was called, and CPR (cardiopulmonary resuscitation) started. Code efforts terminated after 26 mins of CPR. Time of death was reported as 12:06am on 2/26/15. - The complainant, interviewed on 12/01/15 at 1:20pm via phone call indicated when her husband, Patient #1, was transferred to the hospital's ED on 2/25/15. The complainant revealed they tried several times to alert the ED staff of their concerns regarding patient #1's vital signs and trouble breathing but felt ignored. The complainant indicated alarms in the room had sounded several times and the ED ignored them. The complainant reported that their sister in-law is a nurse anesthetist and was shocked that patient #1was extubated prior to transfer. The complainant stated patient #1sat up and said, "I can't breathe". The complainant went out of room and spoke with the ED physician stating patient #1was not doing well. The complaintant indicated that shortly after a call to the Pulmonologist the patient was intubated. The complainant reported her husband needed more critical care than the ER gave. - Physician Staff D, interviewed on 12/02/15 at 3:10pm indicated they remembered patient #1, that a dog bit them in the eye, requiring eye surgery. Staff D admitted patient #1 to the ICU from the ED after being intubated and placed on the Ventilator. Staff D stated they organize where patients are placed, no contact with this patient during their stay. - Physician Staff C interviewed on 12/02/15 at 11:00am indicated patient #1 had come from a surgery center awake and talking, was intubated for the surgical procedure and extubated prior to arriving to ED. Staff C revealed that patient #1's GCS score was 10 and they usually do not intubate until score is eight or below. Staff C indicated that patient #1 was on a non-breather upon arrival to ED and clinically improved until 2:41pm when the patient became more dyspneic and ABG's were ordered. Staff C reported at 4:35pm that patient #1 required intubation due to their clinical presentation and labs. Staff C indicated they consulted a pulmonologist throughout the patient's stay in ED. Staff C indicated they do not extubate patients unless a patient was a DNR and was not informed until family arrives giving the details of the patient wishes then he would extubate. - Registered Nurse Staff G, interviewed on 12/02/15 at 11:05am by phone indicated they remember patient #1 very well. Staff G stated RT Staff O, a Pulmonologist, helped us all evening with patient's condition by phone and Staff O came into the hospital in the evening to speak with family. - RT Staff E, Pulmonologist, interviewed on 12/02/15 at 10:25am indicated patient had come to the ED in critical condition with critical ABG's that were drawn at a surgery center prior to arrival. Patient #1 came to us on a non-breather and progressively worsened. Staff E stated the patient was in acute distress with low oxygen saturations and possible air embolism. Staff E indicated tests were done, the CTA revealed no large defects, air embolism. Staff E indicated patient #1 became more hypoxic and was intubated around 4:45pm and placed on ventilator on high peep settings. Staff E acknowledged that intubating a patient depends on the patient's clinical presentations and lab results combined. During the interview Staff E was shown the critical ABG's that were drawn from the transferring facility at 11:02am on 2/25/15. Staff E stated that with those ABG results they would not have extubated the patient. Staff E acknowledged they would definitely wait for the ordered ABG's results prior to making a decision to extubate. - Registered Nurse Staff F interviewed on 12/02/15 at 12:40pm indicated patient #1 was very anxious when they arrived to the ED. Staff F indicated the physicians were debating due to patient's air hunger to intubate or not, discussing the best medical decision for the patient.