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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance.

A0118 - Standard: Notice of Rights: The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The facility failed to inform the patient who to contact to file a grievance and failed to initiate the grievance procedure on the patient's behalf.

A0143 - Standard: Patient Rights: Personal Privacy. The patient has the right to personal privacy. The facility failed to ensure the personal privacy of patients who received care while placed in hall beds located in the emergency department's corridors.

A0144 - Standard: Patient Rights: Care in a Safe Setting. The patient has the right to receive care in a safe setting. The facility failed to ensure the safety of patients in the Emergency Department (ED) by allowing hall beds, equipment, and patient visitors to obstruct the emergency department corridors. Furthermore, the facility failed to ensure the safety of hall bed patients by neglecting to provide a nurse-call signal system at every hall bed.

Based on interviews and document review, the facility failed to inform the patient who to contact to file a grievance and failed to initiate the grievance procedure on the patient's behalf.

The failures resulted in the patient's grievance not being reported, investigated, and resolved and created the potential for other patient grievances to not be reported, investigated, and resolved.

FINDINGS:

POLICY

According to the facility grievance process, every effort will be made to resolve patient grievances promptly. If concerns cannot be resolved, the director of the appropriate department will attempt a resolution. If a patient remains dissatisfied with the initial attempts at resolution, s/he may initiate a grievance procedure by contacting the Patient Advocate.

1. The facility failed to inform Patient #2 who to contact to file a grievance, failed to initiate the grievance procedure on the patient's behalf, and took away the patient's means to escalate and report the grievance on his/her own.

a) Medical record review revealed Patient #2 received services at the Emergency Department (ED) beginning on 04/14/15.

Review of the Case Management Report, dated 04/17/15, revealed Social Worker #15 (SW) documented the patient stated s/he was being starved, and was being physically abused by a staff member. The patient was initially provided a phone, but the patient's phone privileges were taken away when the patient called the hospital operator and asked to be transferred to the Charge RN so s/he could report the alleged abuse.

b) On 05/06/15 at 9:31 a.m., a telephone interview was conducted with SW #15 who was assigned to the patient when the allegation of abuse occurred. The patient informed SW #15 that s/he was being abused. According to SW #15 the patient stated s/he had food withheld and that she was physically abused by a staff member. SW #15 stated s/he did not consult his/her supervisor regarding this particular patient's abuse allegations because his/her supervisor knew broadly the difficult nature of the patient who was alleging abuse and why the patient was in the Medical Decision Unit for the duration s/he was. SW #15 did not initiate the grievance procedure on the patient ' s behalf and the patient ' s complaint was not investigated and resolved.

c) On 05/06/15 at 9:46 a.m., an interview with the Vice President (VP) of Quality and Performance Improvement confirmed the grievance procedure was not initiated for Patient #2 ' s allegation of abuse, and s/he had no knowledge of the allegation..

Based on observations, interviews, and document review, the facility failed to have a process in place to ensure the personal privacy of patients who received care while placed in hall beds located in the Emergency Department (ED) corridors.

This failure created instances in which patients were asked personal questions, received physical assessments, nursing care, diagnostics, education, and discharge instructions while in open corridors within the Emergency Department without processes in place to ensure their privacy.

FINDINGS:

Policy

According to facility policy, Patient Rights, all patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care.

1. The ED staff provided care to patients in hall beds without ensuring the use of screens, curtains, or other measures to ensure patients' personal privacy and confidentiality of sensitive patient-staff conversations.

a) On 05/04/15 at 9:20 a.m., a tour of the ED was conducted with the Quality Manager, Chief Nursing Officer (CNO), ED Medical Director, ED Manager and Registered Nurse #6 (RN). RN #6 stated the ED was divided into 6 areas: West Wing, East Wing, Pediatric area, Medical Decision Unit, North Wing, and Triage area. In total, the ED had 50 beds which included the triage area.

The hall beds were located in open corridors in the West Wing and East Wing of the ED. Hall bed patients, patients admitted to ED rooms, and visitors to the ED had access to and were moved through the ED corridors. Patients admitted to hall beds were visible to other patients and visitors to the ED.

On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Upon entry to the ED, observation revealed Patient #3 and Patient #4 placed in hall beds in the West Wing of the ED. Patient #4 was observed in hall bed B in street clothes sitting on the edge of the bed. Hall bed B was located across from room 6. Directly down the line of beds, on the same side of the hall, Patient #3 was observed in Hall bed C. Hall bed C was located across from room 5. No privacy screen or curtain was present for either patient. The patients were receiving care in open corridors in which other patients and visitors to the ED also had access.

b) On 05/04/15 at 4:30 p.m., an interview was conducted with RN #8 who stated when all ED rooms were full the patient would be placed in a hall bed so care could be initiated. The care could include a head-to-toe assessment, x-rays, and insertion of an intravenous (IV) catheter while in a hall bed. RN #8 stated s/he would maintain an appropriate level of voice when speaking about care with the patient as a way to ensure privacy.

On 05/05/15 at 2:15 p.m., an interview with RN #13 was conducted. RN #13 stated maintaining privacy was a "difficult one" for patients in hall beds. RN #13 stated s/he would try to use a low tone of voice as a way to ensure patient privacy while in a hall bed. RN #13 stated patients were placed in hall beds every single day because the ED was busy.

c) During a tour of the ED on 05/04/15 at 9:20 a.m., RN #6 stated the normal flow of patients through the ED would be to check in at the front desk and the RN at the desk would determine if the patient would be immediately bedded, in the case of an emergent situation. In the case of a less emergent situation, the patient would go through the Rapid Medical Examination area. The patient could be placed in a hall bed if no ED rooms were available.

During the same ED tour, the ED Medical Director stated the patient's treatment could get started and a Medical Screening Exam (MSE) could be initiated while the patient was in a hall bed.

Also on the same ED tour, the CNO added that the facility would not go on divert if the ED was full, instead they would do "a lot of shuffling" of patients. This meant a patient could be assigned to a hall bed to initiate assessment and treatment, then relocated to an ED room, then relocated back to a hall bed to receive education, discharge instructions, and complete their ED visit.

d) ED medical records and Patient Audit Trail reports were reviewed for 7 patients who received care while in hall beds (Patients #1, #3, #4, #5, #7, #8, and #9). Each of the patients admitted to a hall bed received nursing assessments, which included detailed personal questions. Additionally, patients received medical screening exams, had blood and urine collected, initiation of an IV, and received education and discharge instructions, including a review of home medications. The medical records did not reflect how patient privacy was ensured while sensitive patient information was discussed with the patient in the hallway.

e) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #9 arrived at the ED, on 03/24/15, with a chief complaint of abdominal pain, was admitted to the hospital's ED at 11:40 a.m. and was not admitted to an ED room until 3:23 p.m. (more than 3 1/2 hours later). There was no documentation to show where the patient was located while services were provided during the 3 1/2 hours s/he was not assigned an ED room.

According to Emergency Patient Record review, dated 03/24/15, the patient had the following treatments and assessments performed prior to assignment of an ED room: an ED RN inserted a 20 gauge single lumen peripheral catheter, blood and urine were collected and results were posted by the Laboratory Department.

Patient #9 remained in an ED room, from 3:23 p.m., until being relocated to Hall Bed E at 7:07 p.m. and subsequently discharged at 7:30 p.m. According to the Emergency Patient Record, RN #18 provided wound care to the patient's abdomen and provided discharge instructions and teaching to Patient #9 at 7:19 p.m., while the patient was located in Hall Bed E with no means to ensure his/her privacy.

f) Review of the Patient Audit Trail report, dated 05/05/15, revealed pediatric Patient #4 arrived at the ED, on 05/04/15, with a chief complaint of headache, was admitted to the hospital's ED at 1:41 p.m. and was admitted to Hall Bed C at 2:02 p.m. The patient's entire course of ED assessment, treatment, discharge instructions, and teaching occurred while the patient was in Hall Bed C until s/he was discharged home at 3:58 p.m. (more than two hours later).

Per the Emergency Provider Report, dated 05/04/15, a Medical Screening Exam (MSE) was performed, and medications were ordered and administered while the patient was in Hall Bed C.

According to Emergency Patient Record review, dated 05/05/15, the patient had the following treatments, assessments, and teaching performed while assigned to a hall bed: vital signs and urine were collected, subjective patient assessments including questions about pain and details of the chief complaint were asked, fall risk education was completed, focused physical assessments that included the patient's gastrointestinal system, mucous membranes, and cardiovascular system (including assessment of capillary refill and pedal pulses) were conducted. The ED RN asked the patient questions of abuse, being bullied, medical history, surgical history, immunization history, time and content of last nutritional intake, vomiting episodes in previous 24 hours, and inquired if the patient had recent appetite or feeding changes.

Per Emergency Patient Record review, the patient was diagnosed with UTI/Cystitis, given discharge instructions, discharge education, and received a discharge prescription while s/he was in Hall Bed C.

g) Review of the Patient Audit Trail report, dated 05/05/15, revealed pediatric Patient #3 arrived at the ED, on 05/04/15, with a chief complaint of abdominal pain, vomiting, diarrhea, and headache, was admitted to the hospital's ED at 1:08 p.m. and was assigned Hall Bed B at 2:14 p.m. until s/he was relocated to ED Room 8 at 3:52 p.m. (more than 1 1/2 hours later).

According to Emergency Patient Record, dated 05/04/15, a detailed physical assessment, which included neurological, musculoskeletal, eye, gastrointestinal, genitourinary, respiratory, integumentary, cardiovascular, psychosocial, and circulatory assessments and subjective assessments including pain, chief complaint onset, and frequency of signs and symptoms, was conducted while Patient #3 and family were in Hall Bed B and not assigned to an ED room. The parent received education regarding medications, disease process, safety, discharge planning, procedures, and ED after care.

Additionally, as part of the detailed assessment, Patient #3's parent was asked questions pertaining to his/her child while not assigned to an ED room, such as if s/he was being bullied, if s/he was being threatened by anyone, medical history, surgical history, immunization history, if there were cultural, religious, language, developmental, or behavioral factors to consider in planning the patient's care, if the patient had attempted suicide in the past year, if the patient had any behavioral related complaints, if the patient had any weakness, dizziness, syncope, seizure history, history falling within the last 30 days, inability to bear weight, and if the patient had used medications that cause drowsiness.

h) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #1 arrived at the ED, on 03/05/15, with a chief complaint of headache, was admitted to the hospital's ED at 6:19 p.m., was assigned Hall Bed B and not relocated to an ED Room 6 until 9:33 p.m. (more than 3 hours later).

According to Emergency Patient Record, dated 03/05/15, the patient received a detailed physical assessment, insertion of a peripheral catheter and assessments and reassessments of the patient's head pain.

The patient was asked questions including if s/he thought his/her safety was being threatened by anyone, medical history, surgical history, home medication reconciliation, nutritional assessment, functional assessment, tobacco history, alcohol history, drug use history, cultural, religious, language, developmental, and behavioral factors the staff should consider while providing care to the patient, if s/he experienced weakness, dizziness, syncope or seizure, history of falling in the last 30 days, moderate to severe brain injury, altered loss of consciousness - including drug &/or alcohol impairment, lower extremity neurovascular impairment or inability to bear weight, use of medication causing drowsiness or sedation, any behavioral related complaints (anxiety, depression, aggression, or thoughts of suicide), and if the patient used assistive devices.

According to Emergency Patient Record review, the patient received education and verbalized understanding of the following subject items while in a hall bed and not assigned to an ED room: medications, disease process, pain management, and fall risk education. The patient was encouraged to verbalize anxieties and reassurance was given. The patient was informed of his/her condition and treatment plan, and the patient was encouraged to give input and participate in treatment.

i) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #7 arrived at the ED, on 08/11/14, with a chief complaint of multiple injuries secondary to an assault and was admitted to the hospital's ED at 10:52 a.m. The patient was assigned Hall Bed 1 at 10:59 a.m. until s/he was relocated to ED Room 12 at 11:21 a.m.

According to the Emergency Patient Record, dated 08/11/14, the patient received a detailed assessment and was asked questions regarding if s/he thought her/his safety was being threatened by anyone s/he knew, previous medical history, alcohol history, and drug use history while assigned to a hall bed.

j) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #8 arrived at the ED with a chief complaint of abdominal pain, was admitted to the hospital's ED on 10/21/14 at 11:41 a.m. and was not admitted to an ED room until 2:00 p.m. (over two hours later).

According to Emergency Patient Record review, dated 10/23/14, the patient had the following treatments and assessments performed prior to assignment of an ED room: an ED RN inserted a 20 gauge single lumen peripheral catheter, blood and urine were collected and results were posted by the Laboratory Department. Additionally, the patient was asked personal sensitive questions before s/he was assigned an ED room.

k) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #5 arrived at the ED with a chief complaint of hip pain and was admitted to Hall Bed A on 05/04/15 at 1:05 p.m. until s/he was relocated to ED Room 1 at 1:35 p.m.

According to Emergency Patient Record, dated 05/04/15, the patient received a rapid initial assessment which included questions regarding his/her medical history, surgical history, functional assessment, living arrangements, tobacco history, alcohol history, and drug use history while located in a hall bad with no privacy.

Based on observations, interviews, and document review, the facility failed to ensure the safety of hall bed patients by neglecting to provide a call system for hall beds.

The failure created the potential for an increased risk to patient safety and negative patient outcomes.

FINDINGS:

POLICY

According to the facility policy, Patient Rights and Responsibilities, the patient has a right to reasonable and safe practices and environment.

1. The facility failed to provide a call system for all hall beds in the Emergency Department (ED) for patient use and safety.

a) On 05/04/15 at 9:20 a.m., a tour of the ED with the Quality Manager, Chief Nursing Officer (CNO), ED Medical Director, ED Manager, and Registered Nurse #6 (RN) was conducted. During the ED tour, the ED Medical Director stated every hall bed had a call system. Observations of the ED revealed call systems were not present at 8 of the 8 hall beds (Hall beds A, B, C, D, and 4 unlabeled beds).

In the West Wing hall, across from Exam Rooms 5 and 6, five patient beds were observed in a line against the wall. These beds were labeled Hall A, Hall B, Hall C, Hall D, and one bed without identification. All five beds had a fitted sheet, draw sheet, folded blanket and a patient gown placed on top. Two vital sign machines were observed plugged into the wall between the first two and the last two beds.

During the same ED tour, the ED Medical Director consulted RN #7 regarding call systems for ED hall beds. RN #7 stated none of the hall beds were equipped with a call system. The CNO added the hall beds were used as "more of a staging area."

In the East Wing of the ED, 2 unlabeled beds were observed in the hall. There was 1 bed outside of Room 13 and 1 against the wall between Rooms 17 and 18. Neither of these beds was noted to have a call system. The ED Medical Director stated this was a "true staging area" and patients would not be in the beds very long.

b) On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Observation in the West Hall revealed Hall B had a female patient in street clothes sitting on the bed without a call system and Hall D had an adult male, a young child and Patient #4 holding a white bag for emesis with no access to a call system

During an interview with RN #7 at 3:45 p.m. on 05/04/15, s/he stated hall beds would be in constant vision of the ED staff and a patient could call out if they needed anything. The patients could be on heart monitors and would be able to have vital signs performed. However, RN #7 stated none of the patients in hall beds would have a call system.

Further observation revealed, six of the eight hall beds (A, B, C, and D plus two additional unlabeled hall beds) were not visible by or in close proximity to either of the two nursing stations or either of the two unit secretaries who answered the call system in the ED.

c) On 05/04/15 at 4:20 p.m., an interview with the parent of Patient #3 was conducted in Room 8. The parent stated s/he was in the hall bed for about one hour and was not provided a call system. The parent stated, the nurse said to "grab me if you need me."

Review of Patient #3's Patient Audit Trail report, dated 05/05/15, revealed the patient was placed in Hall C from 2:02 p.m. until 4:06 p.m. (more than two hours without access to a call system) before being moved to Room 8.

d) On 05/05/15 at 2:20 p.m., an interview with RN #13 was conducted in the ED. RN #13 stated if a patient needed something while in a hall bed they could just tell us since they are only "3 feet away, so it is actually an ideal situation." S/he further stated the unit clerk would ask the patient what they needed and the unit clerk would tell the nurse responsible for the patient. According to RN #13, some assessments would be delayed if a patient was in a hall bed. As example, s/he would wait to call for an ultrasound or electrocardiogram (EKG) if a patient was in a hall bed.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.41, PHYSICAL ENVIRONMENT, was out of compliance.

A0725 - Standard: Physical Environment: The extent and complexity of facilities must be determined by the services offered. The facility failed to ensure the Emergency Department was designed to accommodate the volume of patients who presented to and were treated in the Emergency Department (ED).

Based on observations, interviews, and document review the facility failed to ensure the Emergency Department (ED) was designed to accommodate the extent and volume of patients who presented to and were treated in the ED. Furthermore, the facility failed to ensure the safety of hall bed patients by neglecting to provide a call system for hall beds.

The failure created the potential for an increased risk to patient safety related to patients receiving treatment in the emergency department corridors. Additionally, the lack of a call system created the potential for negative patient outcomes.

FINDINGS:

1. The facility was not appropriately designed and equipped for the volume of patients who presented to the Emergency Department.

a) On 05/04/15 at 9:20 a.m., a tour of the ED was conducted with the Quality Manager, Chief Nursing Officer (CNO), ED Medical Director, ED Manager and Registered Nurse #6 (RN). RN #6 stated the ED was divided into 6 areas: West Wing, East Wing, Pediatric area, Medical Decision Unit, North Wing, and Triage area. In total, the ED had 50 beds which included the triage area. Hall beds A, B, C, D were located in the West Wing of the ED. Two unidentified hall beds were located in the East Wing of the ED. The hall beds were positioned in the corridors of the ED.

Observation during the ED tour in the West Wing revealed 5 patient beds in line against the wall across from ED Rooms 5, 6, and 7. These beds were labeled Hall A, Hall B, Hall C, Hall D, and one bed without identification. All five beds had a fitted sheet, draw sheet, folded blanket and a patient gown placed on top. Two vital sign machines on wheels were observed plugged into the wall between the first two and the last two beds. Directly around the corner from Hall D, across from the EMS Lounge, was an unlabeled patient bed. Two additional unlabeled beds were observed in the East Wing. One placed outside of ED Room 17 and one placed outside of ED Room 13. The unlabeled beds had fitted sheets, draw sheets, folded blankets and patient gowns on top of each.

During the same tour, the CNO stated the ED could see over 200 patients a day with 50 beds and would not go on divert when at capacity. The CNO stated last year there were only 10 hours of divert time related to equipment not working. Further, s/he stated the facility had to meet the needs of the community, so there was "a lot of shuffling" to accommodate their volume.

b) On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Observation in the West Wing revealed Hall B, across from ED Room 6, had a female patient in street clothes sitting on the bed without a call system. Hall D, across from ED Room 5, had an adult male, young child, and Patient #4 holding a white emesis bag without a call system. An additional unlabeled bed was observed during this ED tour, in the hall across from the EMS Lounge.

During an interview with RN #7 at 3:45 p.m. on 05/04/15, s/he stated hall beds would be in constant vision of the ED staff and a patient could call out if they needed anything. The patients could be on heart monitors and would be able to have vital signs performed. RN #7 stated none of the patients in hall beds would have a call system.

However, observation revealed 6/8 hall beds (A, B, C, and D plus two additional unlabeled hall beds) were not visible from or in close proximity to either of the two nursing stations or either of the two unit secretaries who answered the call system in the ED.

c) On 05/04/15 at 4:30 p.m., an interview was conducted with RN #8. S/he stated if all the ED rooms were full, a patient would be placed in a hall bed so treatment could be initiated. RN #8 stated a head-to-toe assessment could be performed in a hall bed and an intravenous (IV) catheter could be inserted. The ED staff would have to rely on the patient to flag down a staff member who would find the nurse by checking the RN assignment board, before the patient could receive assistance.

d) On 05/05/15 at 2:20 p.m., during an interview with RN #13, s/he stated some assessments could be delayed if a patient was in a hall bed. RN #13 stated s/he would wait to call for an ultrasound or electrocardiogram (EKG) if a patient was in a hall bed.

e) On 05/05/15 at 2:50 p.m., an interview with RN #7 revealed if a hall bed patient had an emergency s/he would ask the ED staff which patient could be moved from an ED room into the hall so the emergent hall bed patient could have a room. RN #7 stated they constantly shuffled patients in and out of rooms to accommodate their volume of patients.

RN #7 stated if a patient was "sick" enough to need a room "we would do a shuffle" and take another patient out of an ED room and place them in a hall bed so the sick patient could have the room. RN #7 acknowledged a patient could be placed in a hall bed, moved to a room, than placed again in a hall bed because higher acuity and sicker patients received the ED rooms.

f) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #1 arrived at the ED, on 03/05/15, with a chief complaint of headache, was admitted to the hospital's ED at 6:19 p.m., was assigned Hall Bed B and not relocated to an ED room until 9:33 p.m. (more than 3 hours later).

g) On 05/04/15 at 4:20 p.m., an interview with the parent of Patient #3 was conducted in Room 8. The parent stated s/he was in the hall bed for over one hour until provided an ED room, and was not provided a call system. The parent stated, the nurse said to "grab me if you need me." Review of Patient #3's medical record revealed the patient was placed in Hall C from 2:02 p.m. until 4:06 p.m. (more than 2 hours), before being moved to Room 8.

h) On 05/05/15 at 10:57 a.m., an interview with the Patient Representative (PR) was conducted. The PR stated the facility received multiple patient grievances in the past year related to patients being placed in hall beds. S/he stated patients usually felt the ED was so busy that they did not get their basic needs met.

The PR stated Patient #1 was in an ED hall bed for way too long (more than 3 hours). While in the hall bed, the patient was not offered water or pillows for several hours. The PR stated that was "inhumane treatment" and the patient was very upset.

2. The facility failed to provide a call system for all hall beds in the Emergency Department (ED) for patient use and safety.

a) During the tour, on 05/04/15 at 9:20 a.m., the ED Medical Director stated every hall bed had a call system. Observations of the ED revealed call systems were not present at 8 of the 8 hall beds (Hall beds A, B, C, D, and 4 unlabeled beds).

During the same ED tour, the ED Medical Director consulted RN #7 regarding call systems for ED hall beds. RN #7 stated none of the hall beds were equipped with a call system. The CNO added the hall beds were used as "more of a staging area."

In the East Wing of the ED, 2 unlabeled beds were observed in the hall. There was 1 bed outside of Room 13 and 1 against the wall between Rooms 17 and 18. Neither of these beds was noted to have a call system. The ED Medical Director stated this was a "true staging area" and patients would not be in the beds very long.

b) On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Observation in the West Hall revealed Hall B had a female patient in street clothes sitting on the bed without a call system and Hall D had an adult male, a young child and Patient #4 holding a white bag for emesis with no access to a call system

During the interview with RN #7, at 3:45 p.m. on 05/04/15, s/he stated hall beds would be in constant vision of the ED staff but none of the patients in hall beds would have a call system.

Further observation revealed, six of the eight hall beds (A, B, C, and D plus two additional unlabeled hall beds) were not visible by or in close proximity to either of the two nursing stations or either of the two unit secretaries who answer the call system in the ED.

c) On 05/05/15 at 2:20 p.m., an interview with RN #13 was conducted in the ED. RN #13 stated if a patient needed something while in a hall bed they could just tell us since they were only "3 feet away, so it is actually an ideal situation." S/he further stated the unit clerk would ask the patient what they needed and the unit clerk would tell the nurse responsible for the patient and acknowledged the patient did not have access to a call system.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance.

A0118 - Standard: Notice of Rights: The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The facility failed to inform the patient who to contact to file a grievance and failed to initiate the grievance procedure on the patient's behalf.

A0143 - Standard: Patient Rights: Personal Privacy. The patient has the right to personal privacy. The facility failed to ensure the personal privacy of patients who received care while placed in hall beds located in the emergency department's corridors.

A0144 - Standard: Patient Rights: Care in a Safe Setting. The patient has the right to receive care in a safe setting. The facility failed to ensure the safety of patients in the Emergency Department (ED) by allowing hall beds, equipment, and patient visitors to obstruct the emergency department corridors. Furthermore, the facility failed to ensure the safety of hall bed patients by neglecting to provide a nurse-call signal system at every hall bed.

Based on interviews and document review, the facility failed to inform the patient who to contact to file a grievance and failed to initiate the grievance procedure on the patient's behalf.

The failures resulted in the patient's grievance not being reported, investigated, and resolved and created the potential for other patient grievances to not be reported, investigated, and resolved.

FINDINGS:

POLICY

According to the facility grievance process, every effort will be made to resolve patient grievances promptly. If concerns cannot be resolved, the director of the appropriate department will attempt a resolution. If a patient remains dissatisfied with the initial attempts at resolution, s/he may initiate a grievance procedure by contacting the Patient Advocate.

1. The facility failed to inform Patient #2 who to contact to file a grievance, failed to initiate the grievance procedure on the patient's behalf, and took away the patient's means to escalate and report the grievance on his/her own.

a) Medical record review revealed Patient #2 received services at the Emergency Department (ED) beginning on 04/14/15.

Review of the Case Management Report, dated 04/17/15, revealed Social Worker #15 (SW) documented the patient stated s/he was being starved, and was being physically abused by a staff member. The patient was initially provided a phone, but the patient's phone privileges were taken away when the patient called the hospital operator and asked to be transferred to the Charge RN so s/he could report the alleged abuse.

b) On 05/06/15 at 9:31 a.m., a telephone interview was conducted with SW #15 who was assigned to the patient when the allegation of abuse occurred. The patient informed SW #15 that s/he was being abused. According to SW #15 the patient stated s/he had food withheld and that she was physically abused by a staff member. SW #15 stated s/he did not consult his/her supervisor regarding this particular patient's abuse allegations because his/her supervisor knew broadly the difficult nature of the patient who was alleging abuse and why the patient was in the Medical Decision Unit for the duration s/he was. SW #15 did not initiate the grievance procedure on the patient ' s behalf and the patient ' s complaint was not investigated and resolved.

c) On 05/06/15 at 9:46 a.m., an interview with the Vice President (VP) of Quality and Performance Improvement confirmed the grievance procedure was not initiated for Patient #2 ' s allegation of abuse, and s/he had no knowledge of the allegation..

Based on observations, interviews, and document review, the facility failed to have a process in place to ensure the personal privacy of patients who received care while placed in hall beds located in the Emergency Department (ED) corridors.

This failure created instances in which patients were asked personal questions, received physical assessments, nursing care, diagnostics, education, and discharge instructions while in open corridors within the Emergency Department without processes in place to ensure their privacy.

FINDINGS:

Policy

According to facility policy, Patient Rights, all patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care.

1. The ED staff provided care to patients in hall beds without ensuring the use of screens, curtains, or other measures to ensure patients' personal privacy and confidentiality of sensitive patient-staff conversations.

a) On 05/04/15 at 9:20 a.m., a tour of the ED was conducted with the Quality Manager, Chief Nursing Officer (CNO), ED Medical Director, ED Manager and Registered Nurse #6 (RN). RN #6 stated the ED was divided into 6 areas: West Wing, East Wing, Pediatric area, Medical Decision Unit, North Wing, and Triage area. In total, the ED had 50 beds which included the triage area.

The hall beds were located in open corridors in the West Wing and East Wing of the ED. Hall bed patients, patients admitted to ED rooms, and visitors to the ED had access to and were moved through the ED corridors. Patients admitted to hall beds were visible to other patients and visitors to the ED.

On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Upon entry to the ED, observation revealed Patient #3 and Patient #4 placed in hall beds in the West Wing of the ED. Patient #4 was observed in hall bed B in street clothes sitting on the edge of the bed. Hall bed B was located across from room 6. Directly down the line of beds, on the same side of the hall, Patient #3 was observed in Hall bed C. Hall bed C was located across from room 5. No privacy screen or curtain was present for either patient. The patients were receiving care in open corridors in which other patients and visitors to the ED also had access.

b) On 05/04/15 at 4:30 p.m., an interview was conducted with RN #8 who stated when all ED rooms were full the patient would be placed in a hall bed so care could be initiated. The care could include a head-to-toe assessment, x-rays, and insertion of an intravenous (IV) catheter while in a hall bed. RN #8 stated s/he would maintain an appropriate level of voice when speaking about care with the patient as a way to ensure privacy.

On 05/05/15 at 2:15 p.m., an interview with RN #13 was conducted. RN #13 stated maintaining privacy was a "difficult one" for patients in hall beds. RN #13 stated s/he would try to use a low tone of voice as a way to ensure patient privacy while in a hall bed. RN #13 stated patients were placed in hall beds every single day because the ED was busy.

c) During a tour of the ED on 05/04/15 at 9:20 a.m., RN #6 stated the normal flow of patients through the ED would be to check in at the front desk and the RN at the desk would determine if the patient would be immediately bedded, in the case of an emergent situation. In the case of a less emergent situation, the patient would go through the Rapid Medical Examination area. The patient could be placed in a hall bed if no ED rooms were available.

During the same ED tour, the ED Medical Director stated the patient's treatment could get started and a Medical Screening Exam (MSE) could be initiated while the patient was in a hall bed.

Also on the same ED tour, the CNO added that the facility would not go on divert if the ED was full, instead they would do "a lot of shuffling" of patients. This meant a patient could be assigned to a hall bed to initiate assessment and treatment, then relocated to an ED room, then relocated back to a hall bed to receive education, discharge instructions, and complete their ED visit.

d) ED medical records and Patient Audit Trail reports were reviewed for 7 patients who received care while in hall beds (Patients #1, #3, #4, #5, #7, #8, and #9). Each of the patients admitted to a hall bed received nursing assessments, which included detailed personal questions. Additionally, patients received medical screening exams, had blood and urine collected, initiation of an IV, and received education and discharge instructions, including a review of home medications. The medical records did not reflect how patient privacy was ensured while sensitive patient information was discussed with the patient in the hallway.

e) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #9 arrived at the ED, on 03/24/15, with a chief complaint of abdominal pain, was admitted to the hospital's ED at 11:40 a.m. and was not admitted to an ED room until 3:23 p.m. (more than 3 1/2 hours later). There was no documentation to show where the patient was located while services were provided during the 3 1/2 hours s/he was not assigned an ED room.

According to Emergency Patient Record review, dated 03/24/15, the patient had the following treatments and assessments performed prior to assignment of an ED room: an ED RN inserted a 20 gauge single lumen peripheral catheter, blood and urine were collected and results were posted by the Laboratory Department.

Patient #9 remained in an ED room, from 3:23 p.m., until being relocated to Hall Bed E at 7:07 p.m. and subsequently discharged at 7:30 p.m. According to the Emergency Patient Record, RN #18 provided wound care to the patient's abdomen and provided discharge instructions and teaching to Patient #9 at 7:19 p.m., while the patient was located in Hall Bed E with no means to ensure his/her privacy.

f) Review of the Patient Audit Trail report, dated 05/05/15, revealed pediatric Patient #4 arrived at the ED, on 05/04/15, with a chief complaint of headache, was admitted to the hospital's ED at 1:41 p.m. and was admitted to Hall Bed C at 2:02 p.m. The patient's entire course of ED assessment, treatment, discharge instructions, and teaching occurred while the patient was in Hall Bed C until s/he was discharged home at 3:58 p.m. (more than two hours later).

Per the Emergency Provider Report, dated 05/04/15, a Medical Screening Exam (MSE) was performed, and medications were ordered and administered while the patient was in Hall Bed C.

According to Emergency Patient Record review, dated 05/05/15, the patient had the following treatments, assessments, and teaching performed while assigned to a hall bed: vital signs and urine were collected, subjective patient assessments including questions about pain and details of the chief complaint were asked, fall risk education was completed, focused physical assessments that included the patient's gastrointestinal system, mucous membranes, and cardiovascular system (including assessment of capillary refill and pedal pulses) were conducted. The ED RN asked the patient questions of abuse, being bullied, medical history, surgical history, immunization history, time and content of last nutritional intake, vomiting episodes in previous 24 hours, and inquired if the patient had recent appetite or feeding changes.

Per Emergency Patient Record review, the patient was diagnosed with UTI/Cystitis, given discharge instructions, discharge education, and received a discharge prescription while s/he was in Hall Bed C.

g) Review of the Patient Audit Trail report, dated 05/05/15, revealed pediatric Patient #3 arrived at the ED, on 05/04/15, with a chief complaint of abdominal pain, vomiting, diarrhea, and headache, was admitted to the hospital's ED at 1:08 p.m. and was assigned Hall Bed B at 2:14 p.m. until s/he was relocated to ED Room 8 at 3:52 p.m. (more than 1 1/2 hours later).

According to Emergency Patient Record, dated 05/04/15, a detailed physical assessment, which included neurological, musculoskeletal, eye, gastrointestinal, genitourinary, respiratory, integumentary, cardiovascular, psychosocial, and circulatory assessments and subjective assessments including pain, chief complaint onset, and frequency of signs and symptoms, was conducted while Patient #3 and family were in Hall Bed B and not assigned to an ED room. The parent received education regarding medications, disease process, safety, discharge planning, procedures, and ED after care.

Additionally, as part of the detailed assessment, Patient #3's parent was asked questions pertaining to his/her child while not assigned to an ED room, such as if s/he was being bullied, if s/he was being threatened by anyone, medical history, surgical history, immunization history, if there were cultural, religious, language, developmental, or behavioral factors to consider in planning the patient's care, if the patient had attempted suicide in the past year, if the patient had any behavioral related complaints, if the patient had any weakness, dizziness, syncope, seizure history, history falling within the last 30 days, inability to bear weight, and if the patient had used medications that cause drowsiness.

h) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #1 arrived at the ED, on 03/05/15, with a chief complaint of headache, was admitted to the hospital's ED at 6:19 p.m., was assigned Hall Bed B and not relocated to an ED Room 6 until 9:33 p.m. (more than 3 hours later).

According to Emergency Patient Record, dated 03/05/15, the patient received a detailed physical assessment, insertion of a peripheral catheter and assessments and reassessments of the patient's head pain.

The patient was asked questions including if s/he thought his/her safety was being threatened by anyone, medical history, surgical history, home medication reconciliation, nutritional assessment, functional assessment, tobacco history, alcohol history, drug use history, cultural, religious, language, developmental, and behavioral factors the staff should consider while providing care to the patient, if s/he experienced weakness, dizziness, syncope or seizure, history of falling in the last 30 days, moderate to severe brain injury, altered loss of consciousness - including drug &/or alcohol impairment, lower extremity neurovascular impairment or inability to bear weight, use of medication causing drowsiness or sedation, any behavioral related complaints (anxiety, depression, aggression, or thoughts of suicide), and if the patient used assistive devices.

According to Emergency Patient Record review, the patient received education and verbalized understanding of the following subject items while in a hall bed and not assigned to an ED room: medications, disease process, pain management, and fall risk education. The patient was encouraged to verbalize anxieties and reassurance was given. The patient was informed of his/her condition and treatment plan, and the patient was encouraged to give input and participate in treatment.

i) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #7 arrived at the ED, on 08/11/14, with a chief complaint of multiple injuries secondary to an assault and was admitted to the hospital's ED at 10:52 a.m. The patient was assigned Hall Bed 1 at 10:59 a.m. until s/he was relocated to ED Room 12 at 11:21 a.m.

According to the Emergency Patient Record, dated 08/11/14, the patient received a detailed assessment and was asked questions regarding if s/he thought her/his safety was being threatened by anyone s/he knew, previous medical history, alcohol history, and drug use history while assigned to a hall bed.

j) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #8 arrived at the ED with a chief complaint of abdominal pain, was admitted to the hospital's ED on 10/21/14 at 11:41 a.m. and was not admitted to an ED room until 2:00 p.m. (over two hours later).

According to Emergency Patient Record review, dated 10/23/14, the patient had the following treatments and assessments performed prior to assignment of an ED room: an ED RN inserted a 20 gauge single lumen peripheral catheter, blood and urine were collected and results were posted by the Laboratory Department. Additionally, the patient was asked personal sensitive questions before s/he was assigned an ED room.

k) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #5 arrived at the ED with a chief complaint of hip pain and was admitted to Hall Bed A on 05/04/15 at 1:05 p.m. until s/he was relocated to ED Room 1 at 1:35 p.m.

According to Emergency Patient Record, dated 05/04/15, the patient received a rapid initial assessment which included questions regarding his/her medical history, surgical history, functional assessment, living arrangements, tobacco history, alcohol history, and drug use history while located in a hall bad with no privacy.

Based on observations, interviews, and document review, the facility failed to ensure the safety of hall bed patients by neglecting to provide a call system for hall beds.

The failure created the potential for an increased risk to patient safety and negative patient outcomes.

FINDINGS:

POLICY

According to the facility policy, Patient Rights and Responsibilities, the patient has a right to reasonable and safe practices and environment.

1. The facility failed to provide a call system for all hall beds in the Emergency Department (ED) for patient use and safety.

a) On 05/04/15 at 9:20 a.m., a tour of the ED with the Quality Manager, Chief Nursing Officer (CNO), ED Medical Director, ED Manager, and Registered Nurse #6 (RN) was conducted. During the ED tour, the ED Medical Director stated every hall bed had a call system. Observations of the ED revealed call systems were not present at 8 of the 8 hall beds (Hall beds A, B, C, D, and 4 unlabeled beds).

In the West Wing hall, across from Exam Rooms 5 and 6, five patient beds were observed in a line against the wall. These beds were labeled Hall A, Hall B, Hall C, Hall D, and one bed without identification. All five beds had a fitted sheet, draw sheet, folded blanket and a patient gown placed on top. Two vital sign machines were observed plugged into the wall between the first two and the last two beds.

During the same ED tour, the ED Medical Director consulted RN #7 regarding call systems for ED hall beds. RN #7 stated none of the hall beds were equipped with a call system. The CNO added the hall beds were used as "more of a staging area."

In the East Wing of the ED, 2 unlabeled beds were observed in the hall. There was 1 bed outside of Room 13 and 1 against the wall between Rooms 17 and 18. Neither of these beds was noted to have a call system. The ED Medical Director stated this was a "true staging area" and patients would not be in the beds very long.

b) On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Observation in the West Hall revealed Hall B had a female patient in street clothes sitting on the bed without a call system and Hall D had an adult male, a young child and Patient #4 holding a white bag for emesis with no access to a call system

During an interview with RN #7 at 3:45 p.m. on 05/04/15, s/he stated hall beds would be in constant vision of the ED staff and a patient could call out if they needed anything. The patients could be on heart monitors and would be able to have vital signs performed. However, RN #7 stated none of the patients in hall beds would have a call system.

Further observation revealed, six of the eight hall beds (A, B, C, and D plus two additional unlabeled hall beds) were not visible by or in close proximity to either of the two nursing stations or either of the two unit secretaries who answered the call system in the ED.

c) On 05/04/15 at 4:20 p.m., an interview with the parent of Patient #3 was conducted in Room 8. The parent stated s/he was in the hall bed for about one hour and was not provided a call system. The parent stated, the nurse said to "grab me if you need me."

Review of Patient #3's Patient Audit Trail report, dated 05/05/15, revealed the patient was placed in Hall C from 2:02 p.m. until 4:06 p.m. (more than two hours without access to a call system) before being moved to Room 8.

d) On 05/05/15 at 2:20 p.m., an interview with RN #13 was conducted in the ED. RN #13 stated if a patient needed something while in a hall bed they could just tell us since they are only "3 feet away, so it is actually an ideal situation." S/he further stated the unit clerk would ask the patient what they needed and the unit clerk would tell the nurse responsible for the patient. According to RN #13, some assessments would be delayed if a patient was in a hall bed. As example, s/he would wait to call for an ultrasound or electrocardiogram (EKG) if a patient was in a hall bed.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.41, PHYSICAL ENVIRONMENT, was out of compliance.

A0725 - Standard: Physical Environment: The extent and complexity of facilities must be determined by the services offered. The facility failed to ensure the Emergency Department was designed to accommodate the volume of patients who presented to and were treated in the Emergency Department (ED).

Based on observations, interviews, and document review the facility failed to ensure the Emergency Department (ED) was designed to accommodate the extent and volume of patients who presented to and were treated in the ED. Furthermore, the facility failed to ensure the safety of hall bed patients by neglecting to provide a call system for hall beds.

The failure created the potential for an increased risk to patient safety related to patients receiving treatment in the emergency department corridors. Additionally, the lack of a call system created the potential for negative patient outcomes.

FINDINGS:

1. The facility was not appropriately designed and equipped for the volume of patients who presented to the Emergency Department.

a) On 05/04/15 at 9:20 a.m., a tour of the ED was conducted with the Quality Manager, Chief Nursing Officer (CNO), ED Medical Director, ED Manager and Registered Nurse #6 (RN). RN #6 stated the ED was divided into 6 areas: West Wing, East Wing, Pediatric area, Medical Decision Unit, North Wing, and Triage area. In total, the ED had 50 beds which included the triage area. Hall beds A, B, C, D were located in the West Wing of the ED. Two unidentified hall beds were located in the East Wing of the ED. The hall beds were positioned in the corridors of the ED.

Observation during the ED tour in the West Wing revealed 5 patient beds in line against the wall across from ED Rooms 5, 6, and 7. These beds were labeled Hall A, Hall B, Hall C, Hall D, and one bed without identification. All five beds had a fitted sheet, draw sheet, folded blanket and a patient gown placed on top. Two vital sign machines on wheels were observed plugged into the wall between the first two and the last two beds. Directly around the corner from Hall D, across from the EMS Lounge, was an unlabeled patient bed. Two additional unlabeled beds were observed in the East Wing. One placed outside of ED Room 17 and one placed outside of ED Room 13. The unlabeled beds had fitted sheets, draw sheets, folded blankets and patient gowns on top of each.

During the same tour, the CNO stated the ED could see over 200 patients a day with 50 beds and would not go on divert when at capacity. The CNO stated last year there were only 10 hours of divert time related to equipment not working. Further, s/he stated the facility had to meet the needs of the community, so there was "a lot of shuffling" to accommodate their volume.

b) On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Observation in the West Wing revealed Hall B, across from ED Room 6, had a female patient in street clothes sitting on the bed without a call system. Hall D, across from ED Room 5, had an adult male, young child, and Patient #4 holding a white emesis bag without a call system. An additional unlabeled bed was observed during this ED tour, in the hall across from the EMS Lounge.

During an interview with RN #7 at 3:45 p.m. on 05/04/15, s/he stated hall beds would be in constant vision of the ED staff and a patient could call out if they needed anything. The patients could be on heart monitors and would be able to have vital signs performed. RN #7 stated none of the patients in hall beds would have a call system.

However, observation revealed 6/8 hall beds (A, B, C, and D plus two additional unlabeled hall beds) were not visible from or in close proximity to either of the two nursing stations or either of the two unit secretaries who answered the call system in the ED.

c) On 05/04/15 at 4:30 p.m., an interview was conducted with RN #8. S/he stated if all the ED rooms were full, a patient would be placed in a hall bed so treatment could be initiated. RN #8 stated a head-to-toe assessment could be performed in a hall bed and an intravenous (IV) catheter could be inserted. The ED staff would have to rely on the patient to flag down a staff member who would find the nurse by checking the RN assignment board, before the patient could receive assistance.

d) On 05/05/15 at 2:20 p.m., during an interview with RN #13, s/he stated some assessments could be delayed if a patient was in a hall bed. RN #13 stated s/he would wait to call for an ultrasound or electrocardiogram (EKG) if a patient was in a hall bed.

e) On 05/05/15 at 2:50 p.m., an interview with RN #7 revealed if a hall bed patient had an emergency s/he would ask the ED staff which patient could be moved from an ED room into the hall so the emergent hall bed patient could have a room. RN #7 stated they constantly shuffled patients in and out of rooms to accommodate their volume of patients.

RN #7 stated if a patient was "sick" enough to need a room "we would do a shuffle" and take another patient out of an ED room and place them in a hall bed so the sick patient could have the room. RN #7 acknowledged a patient could be placed in a hall bed, moved to a room, than placed again in a hall bed because higher acuity and sicker patients received the ED rooms.

f) Review of the Patient Audit Trail report, dated 05/05/15, revealed Patient #1 arrived at the ED, on 03/05/15, with a chief complaint of headache, was admitted to the hospital's ED at 6:19 p.m., was assigned Hall Bed B and not relocated to an ED room until 9:33 p.m. (more than 3 hours later).

g) On 05/04/15 at 4:20 p.m., an interview with the parent of Patient #3 was conducted in Room 8. The parent stated s/he was in the hall bed for over one hour until provided an ED room, and was not provided a call system. The parent stated, the nurse said to "grab me if you need me." Review of Patient #3's medical record revealed the patient was placed in Hall C from 2:02 p.m. until 4:06 p.m. (more than 2 hours), before being moved to Room 8.

h) On 05/05/15 at 10:57 a.m., an interview with the Patient Representative (PR) was conducted. The PR stated the facility received multiple patient grievances in the past year related to patients being placed in hall beds. S/he stated patients usually felt the ED was so busy that they did not get their basic needs met.

The PR stated Patient #1 was in an ED hall bed for way too long (more than 3 hours). While in the hall bed, the patient was not offered water or pillows for several hours. The PR stated that was "inhumane treatment" and the patient was very upset.

2. The facility failed to provide a call system for all hall beds in the Emergency Department (ED) for patient use and safety.

a) During the tour, on 05/04/15 at 9:20 a.m., the ED Medical Director stated every hall bed had a call system. Observations of the ED revealed call systems were not present at 8 of the 8 hall beds (Hall beds A, B, C, D, and 4 unlabeled beds).

During the same ED tour, the ED Medical Director consulted RN #7 regarding call systems for ED hall beds. RN #7 stated none of the hall beds were equipped with a call system. The CNO added the hall beds were used as "more of a staging area."

In the East Wing of the ED, 2 unlabeled beds were observed in the hall. There was 1 bed outside of Room 13 and 1 against the wall between Rooms 17 and 18. Neither of these beds was noted to have a call system. The ED Medical Director stated this was a "true staging area" and patients would not be in the beds very long.

b) On 05/04/15 at 3:40 p.m., an additional tour of the ED was conducted. Observation in the West Hall revealed Hall B had a female patient in street clothes sitting on the bed without a call system and Hall D had an adult male, a young child and Patient #4 holding a white bag for emesis with no access to a call system

During the interview with RN #7, at 3:45 p.m. on 05/04/15, s/he stated hall beds would be in constant vision of the ED staff but none of the patients in hall beds would have a call system.

Further observation revealed, six of the eight hall beds (A, B, C, and D plus two additional unlabeled hall beds) were not visible by or in close proximity to either of the two nursing stations or either of the two unit secretaries who answer the call system in the ED.

c) On 05/05/15 at 2:20 p.m., an interview with RN #13 was conducted in the ED. RN #13 stated if a patient needed something while in a hall bed they could just tell us since they were only "3 feet away, so it is actually an ideal situation." S/he further stated the unit clerk would ask the patient what they needed and the unit clerk would tell the nurse responsible for the patient and acknowledged the patient did not have access to a call system.