HospitalInspections.org

Based on interviews, record and document review, the facility boards (holds) patients in the emergency department (ED) after their status has been changed to inpatient or observation, because there are no beds available. The facility failed to have a process in place to ensure the patients right to a safe environment. Specifically, protection for the patients emotional health (dignity and comfort). One patient (P)1, over 400 pounds, was on the ED gurney for 52 hours without providing a hospital bed appropriate for his size. He fell off the ED gurney and suffered harm.

Finding include:
1) P1 was a 70 year old male who arrived to the ED on 05/01/2023 at 09:49 AM. He had a history of left lower leg (LLE) DVT (Deep Vein Thrombosis/Blood Clot), morbid obesity (weight 405#), hypertension and gout. He presented to the ED with several day history of shortness of breath and chest pain. He remained in the ED as a boarder for 53 hours, and had not been transferred to an inpatient unit. On 05/03/2023 at 03:50 AM, P1 had an unwitnessed fall and was found on the floor. He sustained a three centimeter forehead laceration that required sutures, skin tears to left upper extremity requiring wound care and complained of neck pain. P1's diagnostic exams, cat scan of the head/cervical spine, were negative in findings, and he was placed in a hard cervical collar (device to limit movement).

2) Reviewed the "Falls Management -Post Fall Assessment Tool" completed by the Day Assistant Nurse Manager (ANM). The ANM documented: "patient stated he fell asleep while sitting sidewards on gurney."

3) Reviewed the ED grievances, and noted P1 on the list with comment "Service Alert Complaint." It was explained service alert complaint was something that came to the facility's attention through a patient survey comment. The appropriate unit manager or designee investigates, identifies opportunities for improvement and documents follow up on the "Patient Relations Worksheet." Reviewed the worksheet initiated on June 7, 2023, which included the following:
- The event type included "environment safety."
- Comment: Arrived at the emergency Monday morning. Monday afternoon was told waiting on a bed. Told I was number 15 on waiting list. Spent two nights in the emergency room on a gurney and never got more than two hours of sleep a night. Early Wednesday morning couldn't sleep sat up on the gurney don't know what happened but I was on the floor. ... Suffered head injury and neck injury. ..."
- "...The patient (P1) was on a waiting list to be admitted to the hospital, and held in the ED until one opened up. According to the patient, he had very little sleep for two days because the gurney's metal frame was uncomfortable to lay upon for any period of time. The patient believes that on the morning of 05/03/2023, he fell asleep while sitting on the side of the bed, fell forward and hit his head on a chair resulting in the need for sutures. ...The outcome the patient would like is for adequate sized beds be available for patients in the ED to keep patients safe during prolonged waiting time so other patients won't have similar experience."
- "The family mentioned the fall may have occurred due to the patient not being in a bariatric bed. ..."
- "Assistant ED Nurse Manager's (ANM) response to the issue; As far as the bariatric bed, we do have them in the hospital. I am not sure why it was not requested for this patient and may have just been overlooked. ..."

4) On 08/02/2023 at 09:30 AM, during an interview with the ANM, she confirmed she completed the post fall tool, because the night shift failed to report the incident and complete the report. She explained the RN assigned the patient or Charge Nurse should complete the report, because they have details of the event and could make recommendations to prevent a similar occurrence. The ANM said P1 "was alert and oriented and sat up for comfort." The ANM said the ED does not have any written guidelines or policy regarding boarders or when to request a hospital bed for comfort. She said they do have hospital beds, including bariatric beds available if needed. The ANM went on to say P1 should have had a bariatric bed due to his size and the amount of time he was on the ED gurney.

On 08/02/2023 at 10:30 AM, conducted an interview with the Director of Nursing of Patient Care Services (DPCS), and the Chief Medical Director (CMD). The DPCS explained all falls that occur in the hospital that result in injury, go to the fall committee for review. She said her recall was P1 was sleeping and didn't realize he was on a gurney, rolled and fell off. She went on to say she believed the recommendation was to be on an appropriate size bed (bariatric).

On 08/02/2023 at 11:30 AM, during an interview with the ED Manager (EDM), he said, "This patient (P1) should have been on a bariatric bed." He said it is up to the nurse's discretion when to call for a bed for a boarder. The EDM said there are no policies or guidelines for the care of boarders. He went on to say, the practice is to call for a bed if the patient requests, or says they are uncomfortable on the gurney. The EDM confirmed knowledge of the survey comment. When asked if any changes had been implemented as a result of the investigation, he said no.

Based on interviews and document review, the facility was aware of an increase of Emergency Department (ED) boarders, and the need to reduce the number and amount of time boarded in the ED. Although this was acknowledged as an opportunity for improvement as well as high risk/problem prone, the facility did not have any quality improvement activities, including data to determine the severity of the problem. As a result of this deficiency, there were no initiatives through the QAPI program to address this issue, which involved not only the ED, but the inpatient units. In addition, the ED throughput data was not reported to the Quality Committee, Administration or board.

Findings included:

1) Cross reference F144- Patient Rights: Care in Safe Setting: The facility boards (holds) patients in the emergency department after their status has been changed to inpatient or observation, because there are no beds available. The facility failed to have a process in place to ensure these patients' rights for a safe environment. One boarder (patient (P)1), over 400 pounds, was on the ED gurney for 52 hours without providing a hospital bed appropriate for his size. He fell off the gurney and suffered harm.

2) On 08/02/2023 at 11:30 AM, during an interview with the ED Manager (EDM), he said he pulls the ED throughput data monthly and reports it to the Emergency Department Physician Group. The EDM said he did not know if someone else reported the data to the quality committee, administration or board. The report included volume and process data. The process measures included, but not limited to patient arrival to time of triage, arrival to time seen by provider, arrival to patient admitted, and arrival to discharge. The EDM acknowledged boarding was a big issue for the ED and they have had up to 15 boarders at one time. He said he did not have any data on the boarder volume, boarder length of stay in the ED, or outcomes.

On 08/02/2023 at 01:00 PM, during an interview with the Quality Manager (QM), she acknowledged that boarding in the ED was a significant issue. She said there had been a high number of patients on the "wait list" for short term rehabilitation, as well as long term care beds. The QM went on to say there were no available beds on island, and if they could find beds for these patients, they could accommodate the ones waiting for a bed in the ED. She said the quality committee meets once a month to review their identified quality measures, and she provides a report to senior management. The QM said the inpatient units did not have any process improvement measures related to the boarding issue (i.e. discharge order to actual discharge time), and confirmed the ED throughput data is not reported to the quality committee. She was unsure if the EDM reported the data to administration or the board. The QM said prior to COVID, they had a patient flow committee and it was a big initiative. She said management is looking at an "overall master plan for issue of holds," but we do not have data.

On 08/02/2023 at 02:12 PM, during an interview with the Chief Nursing Executive (CNE), she said administration frequently discuss holds in the ED, and the number of wait listed patients takes away capacity.