HospitalInspections.org

WV00026214
Based on observation, record review, document review and staff interview it was determined the governing body failed to be responsible for the day to day running of the hospital by ensuring all policies were followed and overseeing the medical staff. The governing body failed to ensure the Director of Nursing ensured that all patients in the emergency department (ED) were assessed and/or reassessed while a patient in the ED. The governing body failed to ensure the Medical Director of the ED followed hospital policies and Medical Staff Bylaws and rules and regulations for patients boarded in the ED. These failures have the potential to affect all patients in the hospital (See Tags A 049 and A 092).

WV00026214
Based on observation, record review, document review and staff interview it was determined the governing body failed to ensure the Medical Director (MD) of the facility's Memorial Division emergency department (ED) followed hospital policies and Medical Staff Bylaws and rules and regulations in six (6) of six (6) boarder patients (inpatients who remain in the ED)(patients #8, 9, 10, 11, 12 and 13). This failure has the potential for all boarder patients (patients that are admitted to the ED proper or the ED waiting room) in the ED to receive substandard care by not being transferred to another hospital.

Findings include:

A tour of the facility's ED conducted on 11/15/21 at 12:30 p.m. revealed there were twenty-five (25) beds with eleven (11) boarder patients (patients that are admitted to the ED proper or the ED waiting room).

Review of the medical record for patient #8 revealed the patient presented to the ED with Flank pain and was diagnosed with a kidney stone on 11/15/21 at 9:45 a.m. The patient was admitted as a boarder patient on 11/15/21 at 12:52 p.m. The patient was not assigned a nurse to care for them and had no registered nurse (RN) for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #9 revealed the patient presented to the ED with vertigo (dizziness) and recent falls with pain on 11/9/21 at 11:42 a.m. The patient was admitted as a boarder patient on 11/10/21 at 9:57 a.m. and was ordered neurological exams every four (4) hours, regular diet and fall risk (but allowed to independently to go to the bathroom) and was on a cardiac monitor. No neurological test was completed. The patient did not have any head-to-toe assessments on 11/10/21 and only one (1) head-to-toe assessment on 11/11/21 at 9:00 p.m. The patient was not assigned a nurse to care for them and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #10 revealed the patient presented to the ED on 11/14/21 at 12:29 a.m. with complaints of altered mental status and was diagnosed with uremia. The patient was admitted as a boarder patient on 11/14/21 at 4:07 p.m. The patient was on a cardiac monitor. The patient had one (1) head-to-toe assessment completed on 11/16/21 at 8:06 a.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #11 revealed the patient presented to the ED with a rectal bleed on 11/15/21 at 9:15 a.m. and was admitted as a border patient on 11/15/21 at 1:31 p.m. The patient was on a cardiac monitor. The patient had no assessment as a border patient. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #12 revealed the patient presented to the ED with altered mental status and generalized aches on 11/14/21 at 11:57 a.m. and admitted as a border patient on 11/14/21 at 4:04 p.m. The patient had one (1) head-to-toe assessment completed on 11/16/21 at 11:15 a.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #13 revealed the patient presented to the ED with chest pain and unstable angina on 11/15/21 at 6:52 a.m. and admitted as a boarder patient on 11/15/21 at 8:47 a.m. The patient was ordered a cardiac monitor. The patient had one (1) head-to-toe assessment completed on 11/15/21 at 11:05 p.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the hospital policy titled "Transferring and Receiving Patients EMTALA," published 3/2/21, revealed in part: "Capacity-the ability of the hospital to accept and treat the patient when considering such things as the level of staffing, the availability of beds and equipment ... Capability-the amount and type of physical space, equipment, supplies and services available in the hospital, as well as the level of care that the personnel and medical staff of the hospital can provide ... Appropriate medical personnel shall provide the patient with stabilizing treatment. If the emergency medical condition resolves, or if the patient is stable for discharge, then the patient may be transferred or discharged, as appropriate."

Review of the "Medical Staff Bylaws and Rules and Regulations," effective 2/24/21, revealed in part: "The transfer of a patient with an emergency medical condition from the Emergency Department to another hospital will be made in accordance with the hospital's applicable policy and in compliance with all applicable state and federal laws, such as EMTALA."

Review of the hospital policy titled "Boarder Patients in the Emergency Department," published 1/4/21, revealed in part: "Policy: Charleston Area Medical Center (CAMC) Emergency Services will comply with the guidelines of Governing agencies by providing all patients with comparable needs the same standard of care, treatment and services as patients throughout the hospital ... Complete the admission history and admission assessment in the EMR (electronic medical record)."

Review of the document titled "Transferring of patient to the hospital," revealed the hospital does receive patients from other hospitals while boarding patients, but those patients are a level of care that the facility had the capability and capacity to care for. Examples include heart attack and aneurysm.

Review of an untitled document for boarder patients from 11/10/21 through 11/16/21 revealed a total of one hundred and fifty-five (155) patients were bordered at the facility's ED.

Review of a document titled "Board of Trustees Committee on Quality Thursday September 9, 2021," states in part: "Memorial hospital is averaging 50 closed beds a day and spiking around 80 beds closed per day due to staffing ... General is averaging 12 closed beds a day and spiking around 20's beds closed per day due to staffing ... Memorial Hospital average boarder time for a patient is 8 hours ... General Hospital average boarder time is 11 hours." No solution was mentioned for boarder patients.

Review of a document titled "Medical Executive Committee," dated 9/09/21, states in part: "Command Center Update...we continue to struggle for beds. 3 north at memorial has been established as a low acuity unit and will house patients awaiting transfer to a SNF (skilled nursing facility) ... CEO ... The one thing weighing on people's minds will be elective cases requiring one overnight stay. It may come to a point to hold on these procedures." It should be noted that during this survey the hospital was allowing elective surgeries.

Review of a document titled "Medical Executive Committee," dated 10/14/21, states in part: "Command Center continues to meet on a daily basis. Decision was reached 10/12 to begin opening elective procedures on 10/19 ... The command center will consider reducing meetings to Monday, Wednesday, and Friday instead of every day as volume of cases declined." It should be noted the command center meets to help make decisions on the ED.

An interview conducted on 11/16/21 at 1:00 p.m. with the ED Medical Director (MD) revealed patients have been transferred into the ED to board. The MD stated they do not call for beds (in house) because they know there aren't any and they do not call other hospitals to transfer patients because they know they do not have beds (because the other hospitals are calling them). The MD did not attempt to call out of state for open beds to transfer patients to. The MD agreed they did not document attempts to transfer patients to hospitals with inpatient beds available.

An interview conducted with the Associate Chief Medical Officer (ACMO) for Ambulatory and ED on 11/17/21 at 11:00 a.m. revealed they have tried to transfer patients to a lower level of care (critical access hospitals) when appropriate, but they did not have the capacity either. The ACMO said their expectation is they should try to show due diligence in attempting to transfer patients.

An interview conducted with the MD on 11/16/21 at 1:00 p.m. revealed they agreed the physicians did not document any attempts made to transfer patients to hospitals with inpatient beds available. The MD also said this is brought up at medical staff meetings and nothing is done about it.

An interview was conducted on 11/17/21 at 2:50 p.m. with the Director of Corporate Regulator Compliance (DCRC). The DCRC concurred the Board of Trustee meeting minutes did not have a solution mentioned in the minutes and elective surgeries are occurring.

WV00026214
Based on record review, document review and staff interview it was determined the governing body failed to ensure the Director of Nursing (DON) ensured that all patients in the facility's Memorial Division emergency department (ED) were assessed and/or reassessed that includes vital signs while a patient in the ED and as an ED boarder patient (patient admitted to the ED or ED waiting room) for three (3) of thirteen (13) records reviewed (patients #1, 3 and 7). This failure has the potential for all patients who seek care in the ED to be adversely affected.

Findings include:

Review of the medical record for patient #1 revealed the patient presented to the ED with vertigo (dizziness) and recent falls with pain on 11/9/21 at 11:42 a.m. Neuro exams were ordered every four (4) hours, no neuro exams were completed throughout his ED visit and as an inpatient in the ED the patient was discharged on 11/13/21 at 1:21 p.m.

Review of the medical record for patient #3 revealed the patient presented to the ED with a rectal bleed on 11/15/21 at 9:15 a.m. There was no documentation of a focused gastrointestinal reassessment or vital signs after the initial triage assessment. The patient was admitted as a boarder patient on 11/15/21 at 1:30 p.m.

Review of the medical record for patient #7 revealed the patient presented to the ED on 11/15/21 at 9:45 a.m. with a diagnosis of chest pain and unstable angina. There was no documentation of a focused cardiovascular reassessment, vital signs or a pain reassessment after the initial triage assessment on 11/15/21 at 9:45 a.m. The patient was admitted as a boarder patient on 11/15/21 at 1:00 p.m.

Review of the facility policy titled "Vital Signs (Emergency Departments)," published 4/30/20, revealed in part: "The frequency of reassessment is based on the patient's acuity, condition, history and complaint as directed by the physician; minimally every 4 hours."

Review of the facility policy titled "Triage, emergency department," revised 8/20/21, revealed in part: "Perform a targeted physical assessment, focusing on the patient's primary concern and presenting symptoms ... Because a patient's condition can decline while waiting in the ED, continue to monitor triaged patients who remain in the ED waiting area ... Be sure to document timelines relating to care, the patient's primary concern and relevant subjective and objective data relating to it."

An interview was conducted with the Director of the ED (DED) on 11/17/21 at 8:45 a.m. The DED agreeded the ED was not following their policy for completing focused reassessments and all patients should receive vital signs every hour including boarder patient's. The DED stated, "We use our ED policies for all patients in the ED."

WV00026214
Based on observation, record review, document review and staff interview it was determined the facility failed to ensure all patients who are admitted to the emergency department (ED) waiting room as boarder patients (inpatients who remain in the ED) are afforded the right to personal privacy (See Tag A 143), failed to ensure all patients who are admitted as boarder patients receive care in a safe setting and to remain free from abuse (neglect). This failure has the potential for all patients admitted to the ED waiting room to have their personal space invaded and to be neglected.

WV00026214
Based on observation and staff interview it was determined patients admitted to the facility's Memorial Division emergency department (ED) waiting room as boarder patients lack the ability to have personal privacy and call system. This failure has the potential for all boarder patients admitted to the ED waiting room to lack personal privacy and the inability to have a call light for an emergency.

Findings include:

A tour of the ED was conducted on 11/15/21 at 12:30 p.m. During the tour, the Director of the ED (DED) revealed the ED had twenty-five (25) beds and stated they only had enough nursing staff to staff nineteen (19) of the beds. At the time of the tour, there were eleven (11) patients boarding in the ED. There were no patients boarding in the ED waiting room at the time of the tour. No patient call lights were noted.

An interview was conducted with the DED on 11/15/21 at 12:30 p.m. The DED concurred there is no privacy or call lights for the boarder patients in the ED waiting room and there is often patients in the waiting room as a boarder patient.



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WV00026290
Based on observation and staff interviews it was determined the facility was providing care in the emergency department (ED) waiting room to registered patients. The designated treatment area of the ED waiting room did not provide personal privacy or physical privacy to the patients while being treated. This failure has the potential for all registered ED patients to have a lack of privacy while receiving treatment.

Findings include:

A second tour of the ED main waiting room was conducted on 1/3/22 at 1:36 p.m. Located in the ED waiting room is a dedicated area with a sign reading "Red waiting area, treatment area." No barriers to provide privacy for patients was noted in this area. Three (3) patient chairs, intravenous (IV) poles and a computer on wheels were located in the red waiting area. During the tour, an interview was conducted with Registered Nurse (RN) #1. When asked if patients were treated in this area, RN #1 stated, "Yes." When asked how many patients were treated in this area at the same time, RN #1 stated, "I have had two (2) to three (3) patients at the same time." When asked which staff provides this care to patients, RN #1 stated, "A float nurse or the triage nurse." When asked what treatments are provided in this area, RN #1 stated, "Normal saline (NS) boluses mainly."

An interview was conducted with the DED on 1/3/22 at 2:24 p.m. When asked about privacy for patients seen in the red waiting area in the ED waiting room, the DED stated, "Patients are taken to the triage room to start an IV, then taken back to the treatment area for administration of the IV. Patients are given NS boluses, and some patients are put on monitors in this area. Bed monitors are used." When asked about discharging patients and reviewing medications or history on discharge (d/c), the DED stated, "When a patient is to be discharged, they are taken to the triage area or the medical screening area to discuss discharge orders. These areas allow for privacy." The DED denied any boarders in any ED waiting areas. The DED stated, "We are doing the best we can do with the amount of patients we are seeing on a daily basis." The facility tries to transfer these patients but there are no beds available. The DED concurred the red waiting area was being used as a treatment area.

WV00026214
Based on observation, record review, document review and staff interview it was determined the Director of Nursing failed to ensure the emergency department (ED) had adequate staffing and supervision of care by a registered nurse (See Tags A 392, A 393, A 395 and A 398). This failure has the potential for all patients to be adversely affected.

WV00026214
Based on observation, record review, document review and staff interview it was determined the facility's Memorial Division emergency department (ED) Director of Nursing (DON) failed to ensure an adequate number of registered nurses (RN) were scheduled to care for boarder patients (inpatients who remain in the ED) in the ED. This failure occurred in six (6) of thirteen (13) records reviewed (patients #8, 9, 10, 11, 12 and 13). This failure has the potential to adversely affect all patients who are admitted to the hospital and remain in the ED as a boarder patient.

Findings include:

A tour of the ED was conducted on 11/15/21 at 12:30 p.m. During the tour, the Director of the ED (DED) revealed the ED had twenty-five (25) beds. The DED stated they only had enough nursing staff to staff nineteen (19) of the beds. At the time of the tour, there were eleven (11) patients boarding in the ED proper. There were no patients boarding in the ED waiting room at the time of the tour. The DED stated there is a nurse in the ED waiting room twenty-four (24) hours a day/seven (7) days a week to check vital signs and to triage patients. The DED also stated that if there are boarders in the ED waiting room, nurse managers and coordinators from other departments assist with reassessments and monitoring the patients.

During an interview with the DED on 11/17/21 at 8:25 a.m., they were asked if they had a nurse assigned to a patient who was admitted and boarding in the ED waiting room. The DED replied, "I do not." The DED also stated an assessment would not be done on a boarder patient in the ED waiting room, who was waiting on an inpatient bed. The DED stated the hospital has been operating on crisis mode and they have a command center that everyone comes up with a plan to care for the patients.

Review of the medical record for patient #8 revealed the patient presented to the ED with Flank pain and was diagnosed with a kidney stone on 11/15/21 at 9:45 a.m. The patient was admitted as a boarder patient on 11/15/21 at 12:52 p.m. The patient was not assigned a nurse to care for them and had no RN for supervision of care.

Review of the medical record for patient #9 revealed the patient presented to the ED with vertigo (dizziness) and recent falls with pain on 11/9/21 at 11:42 a.m. The patient was admitted as a boarder patient on 11/10/21 at 9:57 a.m. and was ordered neurological exams every four (4) hours, regular diet and fall risk (but allowed to independently to go to the bathroom) and was on a cardiac monitor. No neurological test was completed. The patient did not have any head-to-toe assessments on 11/10/21 and only one (1) head-to-toe assessment on 11/11/21 at 9:00 p.m. The patient was not assigned a nurse to care for them and had no RN for supervision of care.

Review of the medical record for patient #10 revealed the patient presented to the ED on 11/14/21 at 12:29 a.m. with complaints of altered mental status and was diagnosed with uremia. The patient was admitted as a boarder patient on 11/14/21 at 4:07 p.m. The patient was on a cardiac monitor. The patient had one (1) head-to-toe assessment completed on 11/16/21 at 8:06 a.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care.

Review of the medical record for patient #11 revealed the patient presented to the ED with a rectal bleed on 11/15/21 at 9:15 a.m. and was admitted as a border patient on 11/15/21 at 1:31 p.m. The patient was on a cardiac monitor. The patient had no assessment as a border patient. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care.

Review of the medical record for patient #12 revealed the patient presented to the ED with altered mental status and generalized aches on 11/14/21 at 11:57 a.m. and admitted as a border patient on 11/14/21 at 4:04 p.m. The patient had one (1) head-to-toe assessment completed on 11/16/21 at 11:15 a.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care.

Review of the medical record for patient #13 revealed the patient presented to the ED with chest pain and unstable angina on 11/15/21 at 6:52 a.m. and admitted as a boarder patient on 11/15/21 at 8:47 a.m. The patient was ordered a cardiac monitor. The patient had one (1) head-to-toe assessment completed on 11/15/21 at 11:05 p.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care.

Review of the average daily census on 11/17/21 revealed the facility budgeted for a census of three hundred and sixty (360) patients. At midnight on 11/17/21, the facility had a census two hundred and sixty-four (264). It should be noted the ED was boarding sixteen (16) patients on 11/17/21.

Review of a document titled "Lippincott Procedures - Health History Interview and Physical Assessment," no revision/review date, states in part: "Nursing assessments minimum of every twelve hours or with a change in patient condition ... A registered nurse performs a comprehensive assessment when the patient is admitted to the facility and then reassess the patient at an interval determined by the facility and the patient's condition ... A comprehensive assessment includes a thorough health history interview and physical assessment. The health history includes the patient's primary concern, a history of the current illness, general medical and surgical histories, a family history, a social history, and a review of systems."

An interview was conducted on 11/15/21 at 1:00 p.m. with the ED Medical Director (MD). The MD concurred nursing is not assigned to boarder patients.

During an interview conducted on 11/17/21 at 8:25 a.m., the DED concurred the above medical records were missing assessments and the patients in the ED waiting room are not assigned a RN.

WV00026214
A. Based on observation, record review, document review and staff interview it was determined the facility's Memorial Division emergency department (ED) Director of Nursing (DON) failed to ensure an adequate number of registered nurses (RN) were scheduled to care for boarder patients (inpatients who remain in the ED) in the ED. This failure occurred in six (6) of thirteen (13) records reviewed (patients #8, 9, 10, 11, 12 and 13). This failure has the potential to adversely affect all patients who are admitted to the ED as a boarder patient.

Findings include:

A tour of the ED was conducted on 11/15/21 at 12:30 p.m. During the tour, the DON revealed the ED had twenty-five (25) beds. The DON stated they only had enough nursing staff to staff nineteen (19) of the beds. At the time of the tour, there were eleven (11) patients boarding in the ED. There were no patients boarding in the ED waiting room at the time of the tour. The DON stated there is a nurse in the ED waiting room twenty-four (24) hours a day/seven (7) days a week to check vital signs and to triage patients. The DON also stated that if there are boarders in the ED waiting room, nurse managers and coordinators from other departments assist with reassessments and monitoring the patients.

During an interview with the DON on 11/17/21 at 8:25 a.m., they were asked if they had a nurse assigned to a patient who was admitted and boarding in the ED waiting room. The DON replied, "I do not." The DON also stated an assessment would not be done on a patient in the ED waiting room, who was waiting on an admission. The DON stated the hospital has been operating on crisis mode and they have a command center that everyone comes up with a plan to care for the patients.

Review of the medical record for patient #8 revealed the patient presented to the ED with Flank pain and was diagnosed with a kidney stone on 11/15/21 at 9:45 a.m. The patient was admitted as a boarder patient on 11/15/21 at 12:52 p.m. The patient was not assigned a nurse to care for them and had no registered nurse (RN) for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #9 revealed the patient presented to the ED with vertigo (dizziness) and recent falls with pain on 11/9/21 at 11:42 a.m. The patient was admitted as a boarder patient on 11/10/21 at 9:57 a.m. and was ordered neurological exams every four (4) hours, regular diet and fall risk (but allowed to independently to go to the bathroom) and was on a cardiac monitor. No neurological test was completed. The patient did not have any head-to-toe assessments on 11/10/21 and only one (1) head-to-toe assessment on 11/11/21 at 9:00 p.m. The patient was not assigned a nurse to care for them and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #10 revealed the patient presented to the ED on 11/14/21 at 12:29 a.m. with complaints of altered mental status and was diagnosed with uremia. The patient was admitted as a boarder patient on 11/14/21 at 4:07 p.m. The patient was on a cardiac monitor. The patient had one (1) head-to-toe assessment completed on 11/16/21 at 8:06 a.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #11 revealed the patient presented to the ED with a rectal bleed on 11/15/21 at 9:15 a.m. and was admitted as a border patient on 11/15/21 at 1:31 p.m. The patient was on a cardiac monitor. The patient had no assessment as a border patient. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #12 revealed the patient presented to the ED with altered mental status and generalized aches on 11/14/21 at 11:57 a.m. and admitted as a border patient on 11/14/21 at 4:04 p.m. The patient had one (1) head-to-toe assessment completed on 11/16/21 at 11:15 a.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the medical record for patient #13 revealed the patient presented to the ED with chest pain and unstable angina on 11/15/21 at 6:52 a.m. and admitted as a boarder patient on 11/15/21 at 8:47 a.m. The patient was ordered a cardiac monitor. The patient had one (1) head-to-toe assessment completed on 11/15/21 at 11:05 p.m. No other head-to-toe assessment was noted on the chart prior to exit of this survey. The patient was not assigned a nurse while they were a border patient and had no RN for supervision of care. There was no documentation of an attempt to transfer the patient.

Review of the average daily census on 11/17/21 revealed the facility budgeted for a census of three hundred and sixty (360) patients. At midnight on 11/17/21, the facility had two hundred and sixty-four (264). It should be noted the ED was boarding sixteen (16) patients on 11/17/21.

Review of a document titled "Lippincott Procedures - Health History Interview and Physical Assessment," no revision/review date, states in part: "Nursing assessments minimum of every twelve hours or with a change in patient condition ... A registered nurse performs a comprehensive assessment when the patient is admitted to the facility and then reassess the patient at an interval determined by the facility and the patient's condition ... A comprehensive assessment includes a thorough health history interview and physical assessment. The health history includes the patient's primary concern, a history of the current illness, general medical and surgical histories, a family history, a social history, and a review of systems."

An interview was conducted on 11/15/21 at 1:00 p.m. with the ED Medical Director (MD). The MD concurred nursing is not assigned to boarder patients.

During an interview conducted on 11/17/21 at 8:25 a.m., the DON concurred the above medical records were missing assessments and the patients in the ED waiting room are not assigned a RN.

WV00026214
Based on observation and staff interview it was determined the facility failed to ensure boarder patients (inpatients who remain in the emergency department (ED)) in the facility's Memorial Division ED waiting room have a safety call light or physical privacy to ensure staff are able to respond when the patient has an emergency or needs comfort or other type of care and to ensure patients have personal privacy if they need to use a bedpan. This failure has the potential for ED waiting room boarder patients to be harmed due to the inability to be able to request help through a call system and to have personal privacy to use the restroom (See Tag A 701).

WV00026290

Based on observation and staff interview it was determined the facility failed to provide the minimum requirements of an outpatient emergency treatment area/room in the facility's Memorial Division ED, in one (1) of (1) outpatient emergency treatment area/rooms in the ED. This failure has the potential for all patients treated in the treatment room to not have an emergency call light to contact a staff member (See Tag A 701).

WV00026214
Based on observation and staff interview it was determined the facility failed to ensure boarder patients (inpatients who remain in the emergency department (ED)) in the facility's Memorial Division ED waiting room have a safety call light or physical privacy to ensure staff are able to respond when the patient has an emergency or needs comfort or other type of care and to ensure patients have personal privacy if they need to use a bedpan. This failure has the potential for ED waiting room boarder patients to be harmed due to the inability to be able to request help through a call system and to have personal privacy to use the restroom.

Findings include:

1. A tour of the ED was conducted on 11/15/21 at 12:30 p.m. During the tour, the ED Director of the Nursing Department (DED) revealed the ED had twenty-five (25) beds and stated they only had enough nursing staff to staff nineteen (19) of the beds. At the time of the tour, there were eleven (11) patients boarding in the ED. There were no patients boarding in the ED waiting room at the time of the tour. No patient call lights were noted and no curtains in the ED waiting room to ensure personal privacy.

2. An interview was conducted with the DED on 11/15/21 at 12:30 p.m. The DED concurred there is no privacy for the boarder patients in the ED waiting room and no call lights for them to call for help or comfort.


WV00026290

Based on observation and staff interview it was determined the facility's Memorial Divsion ED failed to provide the minimum requirements of an outpatient emergency treatment area/room. In one (1) of (1) outpatient emergency treatment area/rooms in the ED. This failure has the potential for all patients treated in the treatment room to not have an emergency call light to contact a staff member.

Findings include:

A tour of the Charleston Area Medical Center (CAMC) Memorial Division ED waiting area was conducted on 01/03/21 at 10:15 a.m. and 10:50 a.m. At approximately 10:30 a.m., it was discovered the ED treatment area in the ED waiting room did not have a nurse call system.

An interview was conducted on 01/04/21 at approximately 9:42 a.m. with the CAMC Memorial Hospital ED Clinical Management Coordinator (EDCMC). During the interview the EDCMC stated, "There was only one (1) patient that I started an IV on and gave fluids." The employee stated this occurred on 12/02/21 during the time there was an ED overflow waiting room. A tour of the CAMC Memorial ED overflow waiting room (Cardiology Imaging waiting room) revealed no nurse call system in the waiting area.

A tour of the CAMC General Division ED was conducted on 01/05/21 between 9:00 a.m. and 9:35 a.m. At approximately 9:13 a.m. it was discovered that the CAMC General ED chair treatment area located within the CAMC General ED did not have a nurse call system.