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Federal investigation reviews death of patient, 73, at University of Kansas Health System

KU Health System
Posted at 5:50 PM, May 02, 2023
and last updated 2023-05-02 20:38:42-04

KANSAS CITY, Mo. — The death of a 73-year-old man last September at the University of Kansas Health System is part of a federal investigation into whether the hospital adequately cared for the patient.

The patient is one of two patients under review by the Department of Health and Human Services' Centers for Medicare and Medicaid Services.

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According to the report, released last month, the man arrived at University of Kansas Health System by ambulance complaining of a "nagging cough."

Medical records obtained by federal investigators show the man arriving at the emergency department at 10:38 p.m. on Sept. 12, 2022. The man would be declared dead just hours later.

According to the report, an ambulance arrived at the residence of the man, who is referred to as Patient 15 in the report, at 9:31 p.m. on Sept. 12 for coughing and vomiting. Upon arrival, medical personnel found him sitting on the side of his bed coughing into a trash can.

Patient 15 reported he had begun coughing up a lot of mucus two hours prior to the ambulance's arrival.

Parademics first took his vitals at 10:30 p.m. and he arrived at the KU emergency room at 10:38 p.m.

Just 14 minutes after arriving at the hospital, at around 10:52 p.m., a physician acknowledged Patient 15 had an abnormal electrocardiogram, which detects heart activity and health. Hospital surveillance reviewed by investigators show the patient was taken by wheelchair to the waiting room prior to a medical screening examination (MSE).

Investigators say the patient would never receive that screening before he passed away early the next morning.

Due to his irregular heart rate, which was new symptom for Patient 15, and the fact that he felt “something else was going on with him besides the cough,” he was assessed as a two out of five on a five-level Emergency Severity Index, with level one being most urgent and level five being least urgent.

Patient 15 was last seen awake on camera at 10:55 p.m.

At 10:56 p.m., surveillance video of the emergency department waiting room ended and didn’t resume until 12:34 a..m. the next morning when another person in the waiting room was caught on camera getting the attention of hospital staff for Patient 15.

Staff checked Patient 15’s vitals in the waiting room and found him unresponsive with no pulse.

It was at this point when video captured a hospital staffer pushing Patient 15, whose head was slumped forward and appeared unresponsive, in a wheelchair out of the waiting room and into a trauma bay.

After unsuccessful attempts at resuscitation, Patient 15 was pronounced dead at 12:52 a.m., a little less than 2 ½ hours after arriving at the hospital.

When interviewed and asked why there was no video surveillance for approximately 90 minutes, a senior director of regulatory and risk management at KU said the person in charge of saving the video “just didn’t save in between.”

According to the report, medical records do not show a proper medical screening examination was provided prior to Patient 15 becoming unresponsive.

“The hospital's noncompliance creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death has occurred and is likely to occur to current or future individuals in similar situations if not immediately corrected,” the report states.

The report claims the University of Kansas Health System failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) requirements by not providing Patient 15 with an appropriate MSE.

In its failure to provide an MSE to Patient 15, the hospital also violated its own policies, per the report.

According to the report, hospital staff said if Patient 15 had complained of chest pain, he “may have been bedded sooner.”

According to hospital staff that were interviewed, if there is anything concerning on an electrocardiogram, staff is asked to room that patient immediately. Staff reported there were no rooms available at the time of Patient 15’s electrocardiogram and there were more patients in the emergency room than on average.

KU hospital staff are required to check vital signs of those in the emergency room every two hours. By the time Patient 15 was found unresponsive, he had only been in the emergency room for one hour and 38 minutes.

Patient 15 had a medical history of coronary artery disease, congestive heart failure, diabetes, hypertension and high levels of fats in the blood, according to the report.

In an e-mail Tuesday, a KU Health system spokesperson told KSHB 41 the hospital was aware of the CMS report regarding Patient 15.