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Based on observation, interview, and record review, the facility failed to inform each patient of their patient rights in advance of receiving care to eight of sixteen patients (P4, P5, P6, P11, P12, P13, P14, P15) reviewed when patients was provided care through the emergency department (ED).

Findings Include:

During an observation on 7/9/25 at 10:28 a.m., R-C registered a patient who needed an interpreter and R-C did not obtain an interpreter. R-C offered the patient bill of rights handout, and the patient shrugged her shoulders indicating she did not know what R-C was saying. R-C indicated in the computer that the patient was offered the patient bill of rights handout.

Upon medical record review on 7/9/25 at 10:58 a.m., for P4, P5, P6, P11, P12, P13, P14, and P15 the medical record indicated the question - bill of rights was offered and the box for yes and the box for no was left unchecked.

P4's medical record was reviewed. P4 was admitted to the facility on 7/7/25 when she walked into the ED by herself and was diagnosed with closed compression fracture of L2 vertebra, abdominal distension, and constipation. P4 was discharged from the ED on 7/7/25. P4's diagnoses did not indicate cognitive impairment.

P5's medical record was reviewed. P5 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with right sided weakness and acute nonintractable headache. P5 was discharged from the ED on 7/8/25. P4's diagnoses did not indicate cognitive impairment.

P6's medical record was reviewed. P6 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with unstable angina, chest pain, sick sinus syndrome, and bradycardia. P6 was currently admitted to the facility when chart review happened on 7/9/25. P4's diagnoses did not indicate cognitive impairment.

P11's medical record was reviewed. P11 was admitted to the facility on 7/8/25 when he came into the ED and was discharged from the ED on 7/8/25. P4's diagnoses did not indicate cognitive impairment.

P12's medical record was reviewed. P12 was admitted to the facility on 7/8/25 when she came into the ED and was discharged from the ED on 7/8/25. P4's diagnoses did not indicate cognitive impairment.

P13's medical record was reviewed. P13 was admitted to the facility on 7/7/25 and was transferred to the cardiac special care unit and where he was discharged on 7/8/25. P4's diagnoses did not indicate cognitive impairment.

P14's medical record was reviewed. P14 was admitted to the facility on 7/7/25 when he came into the ED and was discharged from the ED on 7/7/25. P4's diagnoses did not indicate cognitive impairment.

P15's medical record was reviewed. P15 was admitted to the facility on 7/7/25 when he came into the ED and was discharged from the ED on 7/7/25. P4's diagnoses did not indicate cognitive impairment.

During an interview on 7/7/25 at 12:33 p.m., P13 stated he was not informed about his patient rights during his hospital stay, did not know about his rights as a patient, and was not offered the patient bill of rights.

During an interview on 7/7/25 at 12:40 p.m., P14 stated he was not informed about his patient rights during his hospital stay, did not know about his rights as a patient, and was not offered the patient bill of rights.

During an interview on 7/7/25 at 12:47 p.m., registered nurse (RN)-A stated the facility's registration team will offer patients a patient bill of right handout when the patient is registered.

During an interview on 7/7/25 at 1:17 p.m., RN- B stated patients are offered a patient bill of rights handout at check in. RN-B would also explain the patient bill of rights before any treatments are given.

During an interview on 7/7/25 at 1:50 p.m., RN-C stated patients are offered the patient bill of rights handout by the facility's registration team.

During an interview on 7/7/25 at 2:03 p.m., P4 stated she was not informed about her patient rights during her hospital stay, did not know about her rights as a patient, and was not offered the patient bill of rights.

During an interview on 7/8/25 at 11:52 a.m., P11 stated he was not informed about his patient rights during his hospital stay, did not know about his rights as a patient, and was not offered the patient bill of rights.

During an interview on 7/8/25 at 11:55 a.m., P5 stated she was not informed about her patient rights during her hospital stay, did not know about her rights as a patient, and was not offered the patient bill of rights.

During an interview on 7/8/25 at 11:59 a.m., P12 stated she was not informed about her patient rights during her hospital stay, did not know about her rights as a patient, and was not offered the patient bill of rights.

During an interview on 7/8/25 at 1:59 p.m., registration (R)-A stated patients are offered the patient bill of rights handout during the registration process. The patient bill of rights is offered to every patient during registration. R-A stated she will document the patient's response in the registration screen in the computer and there is a place in the registration notes where she would document if the patient accepted or declined the patient bill of rights handout. R-A stated there is increased registration staff turn over in the ED and registration staff are "bypassing" asking the patients if they want the patient bill of rights handout because "there are several patients and not enough staff who know how to properly register patients."

During an interview on 7/8/25 at 2:20 p.m., R-B stated she will offer patients the patient bill of rights handout during "quick registration" when the patient first walks in the door of the ED and if they can't offer the patient bill of rights handout at that point, she will offer it during the full registration when the patient is in their ED room. There is a screen in the computer system that asks if the patient bill of rights handout was offered and the "only answer you can put is yes;" there is not another answer that registration staff can choose from. R-B stated there is several new registration staff in the ED that will answer "yes" that they offered the patient the patient bill of rights handout but not actually offering it to the patients.

During an interview on 7/8/25 at 3:15 p.m., P6 stated she did not know about her rights as a patient and none of the staff offered her the patient bill of rights handout.

During an observation on 7/9/25 at 9:57 a.m., R-A registered two patients and asked if the patient wanted a patient bill of rights handout. Both patients declined.

During an interview on 7/9/25 at 10:04 a.m., P15 stated he did not know about his rights as a patient and none of the staff offered him the patient bill of rights handout.

During an interview on 7/9/25 at 10:24 a.m., P18 stated she did not know about her rights as a patient and none of the staff offered her the patient bill of rights handout.

During an interview on 7/9/25 at 10:27 a.m., P20 stated she did not know about her rights as a patient and none of the staff offered her the patient bill of rights handout.

The facility's policy "Patient Rights" dated 11/11/22 indicated during admission, patients would be offered the patient bill of rights. Documentation that the patient received or declined the patient bill of rights would be part of the medical record.

Based on interview and record review, the facility failed to include the patient in his right to participate in the development and implementation of his care plan for one of one patient (P1) reviewed for care plans. The hospital had an unknown specialized behavioral health care plan for P1 to change into behavioral scrubs and to remove P1's belonging from his possession that was enforced when P1 presented to the emergency department (ED) for abdominal pain and constipation.

Findings include:

P1 presented to the ED on 4/19/25 when he walked into the ED by himself. P1 was diagnosed with abdominal pain and constipation. P1's prior diagnoses included anxiety, bipolar disorder, borderline personality disorder, and opioid dependence. During his ED visit there was no behavioral health concerns. P1's triage notes indicated he did not wish to be dead in the past month, did not have suicidal thoughts in the past month, and did not have any suicidal behaviors in his lifetime. P1 was discharged from the ED on 4/19/25.

P1's nursing progress note dated 4/19/25 indicated P1 refused a security search and removal of his belongings from his person. P1's RN and provider were updated.

A letter sent to P1 on 5/2/25 indicated P1 had a special care plan that was developed for him when he came to the facility. The care plan was created to help promote healing and safe environment for P1 while keeping other patients and staff safe. The care plan indicated P1 would be roomed in ED room 7 or 8 if available; no opiates, benzos, or stimulants to be given in the ED given P1's extensive chemical dependency issues; the ED provider would clearly state the expectations of the workup and encounter from the onset of P1's arrival; a therapeutic search would be done by security with every visit, and if willing change into behavioral health scrubs; patient belongings "WILL" be removed, "each and every time"; P1 would remain in his room and would not wander out in the unit or stand in the doorway; P1 wouldn't only be able to speak to his primary registered nurse (RN) and primary provider; P1 cannot ask to speak to a different RN, charge RN, or different provider; food would only be given if therapeutically appropriate; security would escort P1 out of the facility with every discharge; and the police department (PD) would be called if needed. The letter stated this care plan would apply to every ED visit. The ED Care Plan Committee would review the care plan "typically" every 18 months. The team would take into consideration changes to the care plan based on P1's behaviors and clinical presentation.

The facility's safety reporting and patient feedback tool dated 5/2/25 indicated P1 called and left a message stating P1 was put on a care plan without warning and that he has not had any behaviors to be put on a care plan. On 5/5/25 provider (P)-A reviewed the report intake and stated P1's care plan would be evaluated every 18 months. On 5/6/25 P-A stated he would not change the care plan or engage in further discussion or debate with P1 about the care plan. P1 liked to "look for wedges, things to argue, nitpick, and debate". P-A stated, "continuously negotiating every little detail with P1 would be a full-time job quite frankly". P-B stated he did not think additional or further discussion with P1 would be impactful in "our" decision on the workplace safety care plan at this time.

During an interview on 7/7/25 at 9:06 a.m., P1 stated he went to the ED on 4/19/25 and the ED staff told him he had a care plan and part of that care plan was that they were going to take all his belongings. His visit to the ED on 4/19/25 did not consist of any behavioral concerns. P1 stated he went as though his care plan was degrading. P1 refused to have his belongings removed but eventually gave his belongings up due to staff repeatedly asking for his belongings. P1 stated he likes to have his phone on him while he is in the ED because it helps to calm him down.

During an interview on 7/7/25 at 12:47 p.m., RN-A stated she believe P1 had a care plan in place at one point, but he had "behaved" and the care plan was removed. P1 stated he should not be on a care plan or that his care plan should have been removed when he did not have behaviors.

During an interview on 7/7/25 at 1:17 p.m., RN-B stated she could not recall what interventions were on P1's care plan but that he did have a care plan in place. RN-B stated she has not seen P1 show behaviors "in a long time".

During an interview on 7/8/25 at 11:21 a.m., RN-D stated she would not normally see the patient have their belongings removed without suicidal or homicidal thoughts if they presented to the ED with abdominal pain and constipation. Removing the patient's belongings would not typically be protocol. The removal of patient belongings is at the discretion of the primary nurse. If the patient is abusing their phone by calling emergency services while they are receiving emergency care or if the patient is talking to others who are "ramping" him up, she would remove the patient's belongings. RN-D was unsure why she asked P1 to remove his belongings during his ED visit on 4/19/25.

During an interview on 7/8/25 at 11:29 a.m., RN-E stated security would do a search and remove belongings if the provider deemed the patient to be a harm to themselves or others. It would not be protocol for a patient to come in the ED for abdominal pain and constipation and have a security search done and patient belongings removed. RN-E was unable to recall P1's ED visit from 4/19/25.

During an interview on 7/8/25 at 1:00 p.m., P-A stated patients would have a care plan when patients have an increased number of visits for the same concern. When a patient has a care plan, interdisciplinary team (IDT) will meet once a month, care plans would be reviewed, and P-A would take notes on each patient's facility visits during that month. P-A stated if the patient comes to the ED for a concern and it is not related to the concern that the care plan was used for, then staff are not expected to use the care plan. Providers and clinical staff have access to implement the care plan. If the patient came to the ED for a concern, providers and clinical staff have the authority to implement or not implement the care plan. P-A stated P1's care plan was started on 4/18/24 and is up for review in October of 2025. P1's care plan was "mostly" about behavioral stuff such as firing his nurses, wanting a different provider, and going to the nurses station frequently through his ED visits. The last 20 ED visits for P1 have been "exclusively" about gastrointestinal (GI) concerns. P1's care plan interventions about removing his belongings and changing into behavioral health scrubs was pertaining to behavioral health concerns. If P1 is coming in for GI concerns and does not pertain to any behavioral health concerns, it would not be a priority to implement the care plan. P-A stated pertaining to P1's ED visit on 4/19/25, P1 should have not been asked to do a security therapeutic search of have his belongings taken from him.

An interview was attempted with security (S)-A on 7/9/25 at 9:05 a.m. and 1:13 p.m. with no success.

An interview was attempted with S-B on 7/9/25 at 9:06 a.m. and 1:14 p.m. with no success.

The facility's" Interdisciplinary Plan of Care" policy dated 12/20/23 indicated a patient's plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals. The patient's plan of care would be prioritized based on clinical assessment and patient's health concerns. As patient care needs are identified, it is the responsibility of the health care team, in partnership with the patient and family, to prioritize the care and services delivered so that the patient's most urgent needs are met.

Based on observation and interview, the facility failed to provide personal privacy and dignity for six of ten patients (P3, P4, P5, P6, P7, and P15) when the patients were receiving care in hallway beds in the emergency department (ED).

Findings include:

P3 was admitted to the facility on 4/25/23 when she came to the ED via emergency medical services (EMS) and was diagnosed with cough and hypoxia (low oxygen). P3 was admitted to the facility and was discharged on 4/27/23. P3's diagnoses consisted of mild dementia.

P4 was admitted to the facility on 7/7/25 when she walked into the ED by herself and was diagnosed with closed compression fracture of L2 vertebra, abdominal distension, and constipation. P4 was discharged from the ED on 7/7/25. P4's diagnoses did not indicate cognitive impairment.

P5 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with right sided weakness and acute non-intractable headache. P5 was discharged from the ED on 7/8/25. P5's diagnoses did not indicate cognitive impairment.

P6 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with unstable angina, chest pain, sick sinus syndrome, and bradycardia. P6 was currently admitted to the facility on 7/9/25. P6's diagnoses did not indicate cognitive impairment.

P7 was admitted to the facility on 7/9/25 when she walked into the ED by herself and diagnosed with umbilical hernia without obstruction. P7 was discharged from the ED on 7/9/25.

P15 was admitted to the facility on 7/7/25 when he came into the ED and was discharged from the ED on 7/7/25. P15's diagnoses did not indicate cognitive impairment.

During an interview on 7/7/25 at 9:15 a.m. with family member (FM)-A, FM-A stated P3 was lying in a hallway bed close to the ambulance bay. Whenever the ambulance bay would open, she would get a "blast" of cold air. P3 had a blanket that had a large hole in it, so P3 felt cold throughout her admission. P3 would complain of the loud noises, and she was trying to cover herself up with the blanket because she only had a gown on.

During an interview on 7/7/25 at 2:03 p.m., P4 was observed in a hallway bed in the ED. During the interview, P4 stated she did not feel as though her care was private. P4 needed to use the bathroom, and a staff member asked her if she could use the bed pain in the middle of the hallway on her bed. P4 could not recall the name of the staff member who asked her that. P4 stated she told the staff member that she would never use a bed pan in the hallway and that she would like to go to a closed bathroom.

During an interview on 7/8/25 at 11:04 a.m., ED director (EDD)-A stated she would expect the same level of care for patients in the hallway that patients in ED rooms would get. EDD-A stated when a patient is in a hallway bed and needed to use the bathroom, she would expect staff to either walk them to the bathroom or use assistive devices such as a walker, cane, or wheelchair to escort the patient to the bathroom. EDD-A stated it would be a challenge to provide a patient dignity, confidentiality, and privacy for a patient to use a bed pan in the hallway. If patients are in a bed in the hallway, EDD-A would expect staff to have lower toned conversations when they are providing care to obtain patient's privacy.

During an interview on 7/8/25 at 11:55 a.m., P5 was observed in a hallway bed in the ED. During the interview, P5 stated she "absolutely" did not feel as though her care is private while in the hallway. P5 did not have pants or a bra on and was only in a gown. P5 felt vulnerable being in the hallway surrounded by people.

During an interview on 7/8/25 at 3:15 p.m., P6 was observed in a hallway bed in the ED. During the interview, P6 stated when she needed to use the bathroom, RN-G asked if P6 could use the bed pan in the hallway. RN-G stated the bathroom closest to P6 was in use and that she would have to use the bed pan. P6 felt very uncomfortable doing this.

During an interview on 7/9/25 at 7:43 a.m., supervisor (S)-A stated she would expect the same level of care for patients in the hallway that patients in ED rooms would get. She would expect staff to preserve patient's dignity while in the hallway. S-A stated that some patients would "have" to use a bed pan while in the hallway and that it is an expectation that privacy is maintained while putting the bed pan in and taking the bed pan out. S-A stated it would be "horrible" for a patient to use a bed pain while in the hallway. S-A stated she would "never" want a patient to defecate or urinate while they are surrounded by EMS staff, facility staff, other patients, or visitors. Privacy is maintained for patients in the hallway by having conversations quietly with the patients and some providers will bring patients or family members to a different room to have a private conversation with them.

During an interview on 7/9/25 at 9:23 a.m., RN-G stated she asked P6 if she could use the bed pan in the hallway because P6 had a low heart rate and was concerned about P6 falling. RN-G stated if a patient is in the hallway using a bed pan, she did not "think" it preserves the patient's dignity but "didn't know what else to do".

During an interview on 7/9/25 at 10:06 a.m., P16 was observed in a hallway bed in the ED. P16 stated she did not feel as though she had privacy being out in the hallway on a bed.

During an interview on 7/9/25 at 10:10 a.m., P7 was observed in a hallway bed in the ED. P7 stated she did not feel as though her care was private because everyone was hearing the conversations she was having with the provider. P7 felt as though her dignity was not being preserved.

Email Correspondence dated 7/10/25 at 11:20 a.m. indicated on 7/7/25 the ED was in contingency surge plan at 7:00 a.m., 12:00 p.m., 4:00 p.m. and was in crisis surge plan at 8:00 p.m. On 7/8/25 the ED was in crisis surge plan at 7:00 a.m., 12:00 p.m., and 4:00 p.m. The ED was in contingency surge plan at 8:00 p.m. On 7/9/25 the ED was at contingency surge plan at 7:00 a.m., crisis surge plan at 12:00 p.m., and contingency surge plan at 4:00 p.m.

The facility's "Confidentiality of Health Information" policy dated 2/2/22 indicated it is recommended adding curtains, screens, cubical, dividers, shields, or similar barriers to open areas where oral communications often occur between providers and patients.

The facility's "Surge Plan" policy dated 4/21/25 indicated if the ED was at a contingency stage, it meant the space, staff, and supplies used are not consistent with daily practices, but provide care to a standard that is functionally equivalent to usually patient care practices. If the ED were at the contingency stage, the ED staff would utilize inpatient hallway bed space while patient rooms are being cleaned to facility movement of patients out of the ED and the ED staff would open hallway assignments to patients. If the ED was at a crisis capacity stage, it meant the need to manage increase patient care volume would otherwise severely challenge or exceed the existing structure, a large influx of patients into the ED, and adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care. When the ED is at a crisis capacity stage, ED staff would initiate all open hallway assignments.