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Based on observation, interview and document review, the hospital failed to have a sign in the Emergency Department (ED) waiting room specifying the rights of patients coming to the hospital ED. This resulted in individuals arriving to the ED waiting room being unaware of their rights as a patient at the hospital.


Findings:

The ED was toured on 10/1/15 at 11:40 A.M. The tour was conducted with the Lead ED Nurse. The ED waiting room was under construction. Several signs were posted around the waiting room, but no sign about patient rights was observed. The Lead ED Nurse took the surveyor into the partitioned off construction area. This area was not accessible to patients. A large sign describing patient rights was found leaning against a cabinet, facing inward toward the cabinet. This sign was not viewable from anywhere outside of the small partitioned off construction area. The Lead Nurse stated that the sign was removed by the construction crew and not rehung. She was unaware of this until the time of the tour during survey.

A hospital policy entitled Patient Rights and Responsibilities (rev. 03/15) was reviewed on 10/1/15. Per the policy," (c) These rights, written in English and Spanish, shall be prominently posted."

Based on interview, record and document review, the hospital failed to ensure that the Emergency Department (ED) log (tracking of each patient in the ED) accurately reflected patients times of arrival, triage (information needed to determine urgency and priority of patients care needs) and discharge from the ED for 7 of 30 sampled patients (1,14, 16, 18, 19, 20, 21). The lack of an accurate ED log did not ensure that staff and other health care providers accurately tracked the length of stay for patient seen in the ED from the time of arrival to departure.

Findings:

On 9/30/15 at 2:00 P.M., Emergency Department Medical Records for Patients 1, 14, 16,18, 19, 20, 21 were reviewed with a Registered Nurse (RN) 4.

1. Patient 1 arrived to the ED on 9/24/15 at 6:40 P.M. per the Pre Arrival Summary dated 9/25/15. The hospitals ED Log indicated that Patient 1 checked in to the ED on 9/24/15 at 7:48 P.M.

2. Patient 14 arrived to the ED on 9/24/15 at 6:44 P.M. per the Pre Arrival Summary dated 9/30/15. Patient 14 was discharged from the ED on 9/24/15 at 8:08 P.M. per the Clinical Depart Summary dated 9/30/15. The hospitals ED Log indicated that Patient 14 checked in to the ED on 9/24/15 at 6:48 P.M. and was discharged on 9/24/15 at 8:10 P.M.

3. Patient 16 arrived to the ED on 9/24/15 at 5:43 per the Pre Arrival Summary dated 9/30/15. The hospitals ED Log indicated that Patient 16 checked in to the ED on 9/24/15 at 9/24/15 at 5:51.

4. Patient 18 arrived to the ED on 9/24/15 at 6:14 P.M. per the Pre Arrival Summary dated 9/30/15. The hospitals ED Log indicated that Patient 18 checked in to the ED on 9/24/15 at 6:19 P.M.

5. Patient 19 arrived to the ED on 9/24/15 at 6:43 P.M. per the Pre Arrival Summary dated 9/30/15. The hospitals ED Log indicated that Patient 19 checked in to the ED on 9/24/15 at 6:43 P.M.

6. Patient 20 arrived to the ED on 9/24/15 at 6:39 P.M. per the Pre Arrival Summary dated 9/30/15. Patient 20 was discharged from the ED on 9/24/15 at 9:22 P.M. per the Clinical Depart Summary dated 9/30/15. The hospitals ED Log indicated that Patient 20 checked in to the ED on 9/24/15 at 7:00 P.M. and was discharged on 9/24/15 at 9:26 P.M.

7. Patient 21 arrived to the ED on 9/24/15 at 7:06 P.M. per the Pre Arrival Summary dated 9/30/15.
The hospitals ED Log indicated that Patient 21 checked in to the ED on 9/24/15 at 7:21 P.M.

On 10/6/15 at 9:30 A.M. an interview was conducted with the Emergency Department Manager (EDAM) and the Director of Quality Regulatory (DQR). The EDM acknowledged that the ED log maintained, did not accurately reflect the current times patients checked in and out of the ED.

Based on observation, interview, and record review, the hospital failed to ensure that their Emergency Department (ED) Triage policy was implemented timely for 1 of 30 sampled patients (1). Patient 1 did not receive immediate triage in the ED in accordance with the hospital's own ED triage policy and procedure. Approximately one hour after arrival to the ED, Patient 1 was called for triage (information needed to determine urgency and priority of patients care needs). Patient 1 was found by staff unresponsive in the locked ED waiting room restroom after an attempted suicide.

In addition, ED Registered Nurse (RN) 1, who had received training related to unlocking ED restroom doors, was unable to unlock the ED restroom door where Patient (1) attempted suicide. This resulted in a two minute delay in unlocking the door to assist the patient.

Findings:

1. A video from three surveillance cameras located in the hospital's ED waiting room, dated and time stamped on 9/24/15, was observed and reviewed on 10/1/15 at 7:30 A.M. The following events were observed via the ED surveillance video:

Patient 1 entered the ED waiting room on 9/24/15 at 6:39 P.M. A Security Guard and several other people were observed in the ED waiting room. At 6:41 P.M., RN 3 entered the ED waiting room and took another patient into the ED. At 6:54 P.M., RN 3 entered the ED waiting room and took another patient into the ED. At 7:05 P.M., RN 1 entered the ED waiting room and took another patient into the ED.

At 7:16 P.M., Patient 1 entered the ED waiting room restroom. At 7:36 P.M., RN 1 entered the ED waiting room. Hospital security guard (SG)1 pointed to the ED restroom. SG 1 knocked on the ED waiting room restroom door. The door remained closed. At 7:36 P.M., when there was no response from the person locked in the ED waiting room restroom, RN 1 left the ED waiting room. At 7:38 P.M., RN 2 entered the ED waiting room and opened the ED restroom door. When the door was opened, RN 2 found Patient 1.

On 9/29/15 at 2:15 P.M., an interview was conducted with SG 1 and the Director of Quality and Regulatory (DQR). SG 1 stated that when Patient 1 entered the ED waiting room, SG 1 asked Patient 1 the following questions: name, reason for visit to the ED and the patient's primary physician. According to SG 1, Patient 1 stated that the reason for his visit to the ED was "will only to talk to a doctor." SG 1 stated that he opened the waiting room door and verbalized the information which he obtained from Patient 1 to a Patient Access Staff (PAS)1, who was on the other side of the door in the ED. SG 1 stated that "while the patient (1) was in the ED waiting room, the patient (1) sat down, breathed heavily, stood up and went to the ED restroom, and was in the restroom approximately 15-20 minutes."

On 9/30/15 at 3:00 P.M., an interview was conducted with PAS 1 and the DQR. PAS 1 stated that his responsibilities included obtaining patient names, reason for visit to the ED, and patient's primary care physician. After obtaining that information, the PAS would enter it into a computer, then inform the nurses that a patient arrived at the ED. PAS 1 stated that SG 1 informed him of Patient 1's first name and that the reason for the visit to the ED was that Patient 1 only wanted to talk to a doctor. PAS 1 stated that SG 1 opened the ED waiting room door and relayed Patient 1's information to him. Per PAS 1 he did not physically go into the waiting room to speak with Patient 1. He asked Patient 1 through the open door to the waiting room what his name was. Per PAS 1, Patient 1 only stated his first name. PAS 1 stated he entered the information collected from SG 1 into the computer and informed the nurses that Patient 1 arrived at the ED.

On 9/29/15 at 1:30 P.M., an interview was conducted with RN 1 and the DQR. RN 1 stated that on 9/24/15, she was assigned as the triage nurse, for the evening shift, from 7 P.M until 7 A.M. She stated that as the triage nurse, she screened patients coming in to the ED according to priority. She stated that patients reason for visit were obtained during a handoff report from the day triage nurse, RN 3. She stated that she was busy with other patients and that she did not triage Patient 1 when the patient first arrived. She stated that when she went to the ED waiting room to call Patient 1 for triage, SG 1 informed her that Patient 1 went into the ED restroom. She stated that SG 1 knocked on the restroom door. When there was no answer, RN 1 stated that she didn't know what to do and left the waiting room to get another nurse from the ED.

On 9/29/15 at 5:17 P.M., an interview was conducted with RN 3 and the DQR. RN 3 stated that Patient 1 was the next patient waiting to be triaged at the shift change. After the patients reason for visit was discussed, RN 1 told her that Patient 2 had a higher priority to be seen. RN 3 stated that she did not triage Patient 1.

On 10/2/15 at 7:21 A.M., an interview was conducted with RN 2. RN 2 stated that he was assigned on 9/24/15 as the Expediter nurse (additional triage and resource for nursing staff). RN 2 stated he was able to view Patient 1 (in the waiting room) via the monitor at the nursing station, and was aware that the patient would only talk with a doctor. He stated that Patient 1 was not a priority acuity from what he saw via the monitor and that he appeared stoic. He stated that he did not triage Patient 1 and was not aware that the other triage nurses had not triaged him. He stated that RN 1 came back from the ED waiting room and informed him that she had called Patient 1 back for triage and that the patient was locked in the ED restroom and asked RN 2 for help. RN 2 stated he went to the ED waiting room, unlocked the ED restroom and found Patient 1 with a belt buckle around his neck, and the belt was tied around a wall hook. He stated that he lifted Patient 1 off the wall hook, untied the belt and began cardiopulmonary resuscitation (CPR - emergency medical procedures for restoring normal heartbeat and breathing). He stated that he continued CPR and a code (alert to staff for life sustaining treatment) was called. Patient 1 was transferred back to the ED and later transferred to the intensive care unit (ICU).

On 10/2/15 at 8:37 A.M., an interview was conducted with the Medical Director (MD)1. MD 1 stated that the hospital's expectation was that a patient would be immediately screened for triage in the waiting room. MD 1 acknowledged that this was not implemented in accordance with the hospital's ED triage policy and procedure.

On 10/5/15 at 9:00 A.M., an interview and review of the hospital's policy titled " Triage, dated 8/2014," was conducted with RN 1 and the DQR. The policy indicated "Each patient is evaluated at the time of arrival by a RN." "The triage nurse will obtain information needed to determine urgency of each patient's care needs."

This policy was not implemented when Patient 1 arrived to the ED on 9/24/15 at 6:39 P.M. and was not triaged. At 7:38 P.M., Patient 1 was discovered unconscious in the ED restroom and the patient was transferred to the ICU on 9/24/15 at 9:40 P.M. According to a neurology progress note dated 10/5/15, Patient 1's diagnoses included anoxic brain injury (absence of oxygen to the brain) status post hanging, respiratory failure, on ventilator support (mechanical device that moves breathable air into and out of the lungs).

2. On 9/29/15 at 1:30 P.M., an interview was conducted with RN 1 and the Director of Quality and Regulatory (DQR). RN 1 stated that on 9/24/15 at 7:36 P.M., she entered the Emergency Department (ED) waiting room and called a Patient (1) for triage (information needed to determine urgency and priority of patients care needs).
She stated the following: A hospital security guard (SG)1 pointed to the ED restroom. SG 1 knocked on the ED restroom door. The door remained closed. At 7:36 P.M., when there was no response from the person locked in the ED restroom, RN 1 left the ED waiting room. At 7:38 P.M., RN 2 entered the ED waiting room and opened the ED restroom door. When the door was opened, RN 2 found Patient 1 unresponsive. Furthermore, during the interview, RN 1 stated that she only had a pen and wasn't sure how to open the door and that is when she went to ask RN 2 to unlock the ED restroom door. In addition, RN 1 stated that staff usually open the ED restroom doors with scissors or a dime.

On 10/5/15 at 9:00 A.M., an interview was conducted with RN 1 and the DQR. RN 1 stated that in February 2015, staff received an email related to opening the locked ED restroom doors and that staff used a coin or a screwdriver that was placed on the white board in the ED (staff communication board) however; RN 1 stated the communication board was not visible on 9/24/15 due to a construction project in the ED waiting room.

On 10/5/15 at 9:23 A.M., an interview and review of the ED document titled "Bathroom Lock Access" dated 2/9/15, was conducted with the ED Manager (EDM). The document indicated "The recommended tool to open the bathroom lock is the ED RN or HCP's (Health Care Partners) trauma shears... just put in the rounded part of your shears and turn." "A second method is to use a small coin (such as a penny or dime) to insert in the rounded part of the lock hole and turn." "Or there is always the flat head screwdriver tool in the nursing station (kept with other pens in the holder facing rooms 1-4, just insert and turn."

On 9/24/15 at 7:36 P.M., RN 1 called Patient 1 for triage and SG 1 pointed and knocked on the ED restroom door. When there was no response from the person locked in the ED restroom, RN 1 left the ED waiting room. At 7:38 P.M., RN 2 entered the ED waiting room and opened the ED restroom door. When the door was opened, RN 2 found Patient 1 unresponsive.

Based on the date and time stamped video, there was a two minute delay in assisting Patient 1. This delay did not ensure an immediate intervention was implemented to respond to Patient 1.