HospitalInspections.org

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition §482.13 Patient Rights, was out of compliance.

A-0143 The patient has the right to personal privacy. Based on observation, document review, and interviews, the facility failed to ensure the personal privacy of five of five patients reviewed who received care while placed in hall beds located in the emergency department (ED)(Patients #1, #4, #5, #6, and #8).

A-0144 The patient has the right to receive care in a safe setting. Based on observations, document reviews, and interviews, the facility failed to ensure the safety of hall bed patients in the emergency department (ED) by neglecting to provide a call system in five of five patient observations (Patients #1, #4, #5, #6, and #8). Furthermore, the facility failed to ensure the minimal usage of hallway beds, and when used, the facility failed to ensure the safety of hall bed patients by its lack of policy, procedure, and guidance to the staff on the care of hall bed patients. (Cross reference A-0143)

Based on observations, document review, and interviews, the facility failed to ensure the personal privacy of five of five patients reviewed who received care while placed in hall beds located in the emergency department (ED)(Patients #1, #4, #5, #6, and #8).

Findings include:

Facility policy:

The facility Patient Rights and Responsibilities policy read, its purpose is to communicate and provide patient rights and responsibilities to all patients with recognition of the patient's personal values and beliefs as long as they do not interfere with the well-being of others or the patient's medical treatment. The policy is to provide care and treatment in a safe setting that is respectful, recognizes a person's dignity, cultural values, and religious beliefs and preferences, and provides for personal privacy to the extent possible during the course of treatment.

1. The facility failed to have a process in place to ensure the personal privacy of patients who received care while placed in hall beds.

A. Observations

i. On 12/26/23 at 8:55 a.m., a tour of the ED was conducted with clinical nurse manager (Manager) #4. According to Manager #4, the ED was divided into 4 areas: main ED, senior ED, behavioral health, and fast-track and triage area. In total, the ED had 52 beds which included the triage area. Hall beds #24, #28, #32, #37, and #40 were designated in the main area of the ED. Two additional hall beds #48 and #54 were designated in the senior area of the ED.

The hall beds were positioned in the open corridors of the ED. Hall bed patients, patients admitted to ED rooms, and ED visitors had access to and were observed walking through the open corridors. This left patients admitted to hall beds visible to other patients and visitors in the ED.

During the tour, hall bed stretchers were observed with clean sheets and supplies and appeared ready to receive patients. Manager #4 stated the beds were prepared in case they were needed for lower acuity patients when the rooms were all full. Additionally, Manager #4 described the ED track board and pointed out the location of hall beds on the track board.

ii. On 12/26/23 at 2:47 p.m., an additional ED observation was conducted. Observations revealed Patient #4 was in hall bed #37 next to the nurse's station, however, there was nothing in place to protect the patient's privacy while receiving care in the hallway.

a. A review of Patient #4's medical record revealed they were admitted to the ED for syncope (fainting) and were triaged as an ESI-3 (stable and less acute patient whose condition required two or more resources for a disposition to be made). Patient #4 moved from ED room #35 to ED hall bed #37 at 1:13 p.m., and discharged from hall bed #37 by ambulance transport to home on 12/26/23 at 4:20 p.m. Patient #4 spent a total of three hours in a hall bed with no means in place to protect their privacy.

iii. On 12/28/23 at 3:05 p.m., an additional ED observation was conducted. The director of emergency services (Director) #6 was present at the time of the observation. Observations revealed all five hall beds were in use during the observation period. During this time, approximately half of the rooms in the senior ED section of the ED were empty. Director #6 said there had been multiple staff call-outs that day and they were actively recruiting staff to come in so they could open the rest of the beds in the senior ED section.

a. Further observations during this time revealed the patient and visitor located in hall bed #32 were able to observe staff providing care to a female patient, Patient #7, who was not fully clothed, in trauma room #32. The privacy curtains were not pulled to protect Patient #7's privacy. Patient #7's care was in direct line of sight of the patient and visitor in hall bed #32.

b. Further observations during this time revealed Patient #5 was located in hall bed #37 and received a 12-lead electrocardiogram (EKG), lab draw, ultra-sound guided intravenous (IV) catheter placement, and a care management consult in the corridor with nothing in place to protect their privacy. Staff, patients, and visitors were observed walking past Patient #5 while they were receiving patient care services.

A review of Patient #5's medical record revealed they were brought to the ED by ambulance after having several falls at their nursing facility that day. The nursing facility also reported the patient had been having increased agitation and aggressive behaviors. Patient #37 had a history of cognitive impairment and a behavioral disorder. Patient #5 was triaged as an ESI-3. Patient #5 was placed in hall bed #37 on 12/28/23 at 2:52 p.m., and moved to room SR49 on 12/28/23 at 8:23 p.m. Patient #5 spent a total of five and a half hours in a hall bed without a way to protect their privacy.

c. Further observations during this time revealed Patient #6 was located in hall bed #32 and received a nasal swab while in the hallway to collect a specimen for a respiratory panel that could detect a respiratory infection such as COVID or influenza with no way to protect their privacy.

A review of Patient #6's medical record revealed they were brought to the ED by ambulance from their home with shortness of breath. They were triaged a level ESI-2 (urgent level two patient, very ill and should be seen as soon as possible) and placed in ED hall bed #32 on 12/28/23 at 4:39 p.m. Patient #6 was moved to ED room 34 at 5:58 p.m. Patient #6 spent a total of one hour and ten minutes in a hall bed without a way to protect their privacy.

iv. Observations were conducted of video camera footage from 12/7/23 from 2:45 p.m. to 8:15 p.m. in the main ED. Observations revealed two patients were located on stretchers in the hallway by the nursing station. There was nothing in place to protect their privacy while receiving care in the hallway.

a. Further observations from the video camera footage revealed Patient #1 was in hall bed #37 across from ED room #37 wearing street clothes and lying on a stretcher with nothing in place to protect their privacy. The patient received triage assessment (the process of sorting patients based on their need for immediate medical treatment), lab draw, IV catheter insertion, 12-lead EKG, a care management consult, and a physical therapy evaluation in the hallway.

A review of Patient #1's medical record revealed they were brought to the ED by ambulance from urgent care where they had been evaluated for recent falls and weakness. A head CT had been conducted at the urgent care. Patient #1 was triaged at a level ESI-3 and placed in ED hall bed #37 at 2:54 p.m. Documentation revealed at 7:07 p.m. the nurse could not find an available wheelchair to transport the patient to the bathroom so a urinal was provided to the patient in the hallway under a sheet for modesty. Patient #37 was moved to ED room 23 at 7:56 p.m. Patient #5 spent a total of five hours in a hall bed without a way to protect their privacy.

b. Further observations from the video camera footage revealed Patient #8 was in hall bed #32 across from ED room #32 wearing street clothes and lying on a stretcher without a way to protect their privacy. The patient received triage assessment, vital signs, lab draw, IV catheter insertion, and 12-lead EKG in the hallway. During the observation of the 12-lead EKG, the patient's abdomen was visible throughout the procedure.

A review of Patient #8's medical record revealed they were brought to the ED by ambulance for weakness and respiratory distress. Patient #8 was triaged level ESI-2 and placed in ED hall bed #32 at 12:56 p.m. They were moved to ED room #32 at 4:32 p.m. Patient #8 spent a total of three and a half hours in a hall bed without anything in place to protect their privacy.

This was in contrast to the Patient Rights and Responsibilities policy which read, staff were to provide care and treatment in a safe and respectful setting, that recognized a person's dignity, cultural values and religious beliefs, and preferences, and provided for personal privacy to the extent possible during treatment.

B. Interviews

i. On 12/28/23 at 8:10 a.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated when they assessed patients they needed to ask private questions and it was a challenge when the patient was located in the hall bed. RN#7 stated they tried hard to protect patient privacy, for example, if there was a patient in a room nearby they would close the door to that room, or if a visitor was in the hallway they would ask the visitor to step into the room; or if someone was walking by they would wait until they walked by and then continue talking to the patient.

RN #7 stated as far as physical privacy, they attempted to find a room or space for privacy and moved the patient there to conduct an exam or to provide personal care. They said a lot of patient care was done in the hallway which included IV catheter insertions, medication administrations, and the majority of the physical exam. Further, they said a patient would have their test results spoken in the hallway. They explained this sometimes caused delays in talking to patients in the main ED because, for example, if a brain tumor was seen on imaging, they would need to find a private area to give the test results to the patient.

ii. On 12/26/23 at 8:55 a.m., an interview was conducted with clinical nurse manager (Manager) #4 while touring the ED. Manager #4 confirmed the use of hall beds in the ED. They said patients who were low acuity, were ready for discharge, or who had tests pending would be placed in a hall bed. Manager #4 stated patients should have been moved to a private treatment room for care that required privacy. Further, they said there was no formal written policy or process to determine which patient was assigned a hall bed. Additionally, they said the ED utilized hall beds when it was at capacity for patients or when there was not enough staff to assign a patient to a private room. Manager #4 confirmed that hall beds had a designation on the patient tracking system.

iii. On 1/2/24 at 12:32 p.m., an interview was conducted with the director of emergency services (Director) #6. Director #6 stated patients had the right to privacy. They said hall bed patients were given privacy to the best of their ability. They also said hall bed patients received the same care as a patient in a private treatment room. Director #6 stated they were not sure if ED staff had received training on hall bed care.

iv. On 12/28/23 at 1:51 p.m., an interview was conducted with ED physician (MD) #8. MD #8 stated they had cared for hall bed patients when the ED was full. They said they did a full exam, to a certain degree, in the hallway and protected the privacy of the patient as much as possible. MD #8 stated they minimized personal medical information discussed in the hallway. They said they were limited because they could not discuss confidential information when patient history was discussed in the hallway to protect the personal health information of the patient. Further, they stated the biggest limitation was the lack of privacy in the hallway to remove clothing for physical assessment. MD #8 said if it was physically important and the patient needed a more private exam, they found a space to make that happen. Additionally, they said this often meant they needed to switch rooms with another patient.

v. On 12/28/23 at 7:40 a.m., an interview was conducted with medical director (Director) #1. Director #1 stated they would speak quietly with hall bed patients to protect their privacy. Also, they sometimes found a private place for conversation. They stated for the physical exam they did what they could privately in the hallway. Director #1 stated they would swap patients temporarily or permanently if privacy was needed.

Director #1 stated hall beds were used as a "pop-off valve" when space was not adequate to meet patient needs or volume. They said there was no policy for hall bed care. Further, they said hall beds were used as a last resort and that no one wanted to be in a hall bed.

This was in contrast to the Patient Rights and Responsibilities policy which read, staff were to provide care and treatment in a safe and respectful setting, that recognized a person's dignity, cultural values and religious beliefs, and preferences, and provided for personal privacy to the extent possible during treatment.

Based on observations, document reviews, and interviews, the facility failed to ensure the safety of hall bed patients in the emergency department (ED) by neglecting to provide a call system in five of five patient observations (Patients #1, #4, #5, #6, and #8). Furthermore, the facility failed to ensure the minimal usage of hallway beds, and when used, the facility failed to ensure the safety of hall bed patients by its lack of policy, procedure, and guidance to the staff on the care of hall bed patients. (Cross reference A-0143)

Findings include:

Facility policies:

The facility Patient Rights and Responsibilities policy read, its purpose is to communicate and provide patient rights and responsibilities to all patients with recognition of the patient's personal values and beliefs as long as they do not interfere with the well-being of others or the patient's medical treatment. The policy is to provide care and treatment in a safe setting that is respectful, recognizes a person's dignity, cultural values, and religious beliefs and preferences, and provides for personal privacy to the extent possible during the course of treatment.

The facility ED Triage policy read, its purpose is to prioritize patient needs to the available resources of the Emergency Department, a 5-level evidence-based standardized triage process will be followed. The purpose of triage in the emergency department (ED) is to prioritize incoming patients and to identify those who cannot wait to be seen. The triage nurse performs a brief, focused assessment and assigns the patient a triage acuity level, which is a proxy measure of how long an individual patient can safely wait for a medical screening examination and treatment.

Definitions: Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the individual will be seen by a physician or other qualified medical personnel (QMP). ESI 1 - Resuscitative/ Emergent Level 1 patients are critically ill and require immediate physician evaluation and interventions. ESI 2 - Urgent Level 2 patients are very ill and should be seen as soon as possible. Emergency care can be initiated through protocols without a physician at the bedside.
The patient needs interventions, but their clinical condition will not deteriorate. Included but not limited to: High-Risk Situations, New onset confusion, lethargy, or disorientation, and severe pain or distress. ESI 3 - Stable Less acute patients whose condition requires 2 or more resources for a disposition to be made. ESI 4 - Non-urgent Less acute patients whose condition requires a single resource for a disposition to be made. ESI 5 - Non-urgent Less acute patients whose conditions require no resources for a disposition to be made.

1. The facility failed to provide a nurse call system for all patients who received care in an ED hall bed.

A. Observations and Medical Record Reviews

i. On 12/26/23 at 2:47 p.m., an observation was conducted of the main ED. One patient (Patient #4) was located on a stretcher alone in the hallway. The patient did not have access to a nurse call system. Observations further revealed Patient #4 was in hall bed #37 across from ED room #37 wearing street clothes and lying on a stretcher without a call system.

Review of Patient #4's medical record revealed they were admitted to the ED for syncope (fainting). They received a CT of the head and cervical spine during their evaluation in the ED. After they were evaluated, Patient #4 was prepared to be discharged and was moved from ED room #35 to ED hall bed #37 at 1:13 p.m. to wait for ambulance transport. They were discharged from hall bed #37 on 12/26/23 at 4:20 p.m. Patient #4 spent a total of three hours in a hall bed without access to a nurse call light.

ii. On 12/28/23 at 3:05 p.m., an additional observation was conducted of the main ED. Five patients were located on stretchers in the hallway. The patients did not have access to a nurse call system. The director of emergency services (Director) #6 was present at the time of the observation. Observations confirmed that five hall beds were in use during the observation period. During this time, approximately half of the rooms in the senior ED section of the ED were empty. Director #6 said there had been multiple staff call-outs that day and they were actively recruiting staff to come in so they could open the rest of the beds in the senior ED section.

a. Observations further revealed Patient #6 was in ED hall bed #32 across from ED room 32 wearing street clothes, and lying on a stretcher without a call system.

A review of Patient #6's medical record revealed they were brought to the ED by ambulance from their home with shortness of breath. They were triaged a level ESI-2 and placed in ED hall bed #32 at 4:39 p.m. Patient #6 received a nasal swab while in the hallway to collect a specimen for a respiratory panel that could detect a respiratory infection such as COVID or influenza. At 5:58 p.m. they were moved to ED room 34. Patient #6 spent a total of one hour and ten minutes in a hall bed without access to a nurse call light.

b. Observations further revealed Patient #5 was in hall bed #37 across from ED room #37 wearing street clothes and lying on a stretcher without a call system.

A review of Patient #5's medical record revealed they were brought to the ED by ambulance after having several falls at their nursing facility that day. The nursing facility also reported they had been having increased agitation and aggressive behaviors. Patient #37 had a history of cognitive impairment and a behavioral disorder. Patient #5 was triaged as an ESI-3 and placed in ED hall bed #37 at 2:52 p.m. At 8:23 p.m. they were moved to ED room SR49. Patient #5 spent a total of three and a half hours in a hall bed without access to a nurse call light.

iii. Observations were conducted of video camera footage from 12/7/23 at 2:45 p.m. to 8:15 p.m. in the main ED. Two patients were located on stretchers in the hallway. The patients did not have access to a nurse call system.

a. Observations further revealed Patient #1 was in hall bed #37 across from ED room #37 wearing street clothes, lying on a stretcher alone and without a call system. A visitor was observed arriving at their hall bed approximately ten minutes after the patient arrived.

A review of Patient #1's medical record revealed they were brought to the ED by ambulance from urgent care where they had been evaluated for recent falls and weakness. A head CT had been conducted at the urgent care. Patient #1 was triaged a level ESI-3 and placed in ED hall bed #37 at 2:54 p.m. At 7:56 p.m. they were moved to ED room 23. Patient #5 spent a total of five hours in a hall bed without access to a nurse call light.

b. Observations further revealed Patient #8 was in hall bed #32 across from ED room #32 wearing street clothes and lying on a stretcher alone and without a call system.

A review of Patient #8's medical record revealed they were brought to the ED by ambulance for weakness and respiratory distress. They were triaged a level ESI-2 and placed in ED hall bed #32 at 12:56 p.m. At 4:32 p.m. they were moved to ED room 32. Patient #8 spent a total of three and a half hours in a hall bed without access to a nurse call light.

These observations and medical record reviews were in contrast to the Patient Rights and Responsibilities policy which read, patients were to receive care and treatment in a safe setting.

B. Interviews

i. On 12/26/23 at 9:46 a.m., an interview was conducted with emergency department technician (EDT) #2. EDT #2 stated patients placed in ED hall beds did not have access to a nurse call light. Also, EDT #2 said they were not sure if a staff member was always present at the nursing station to observe hall bed patients who did not have access to a call light.

ii. On 12/26/23 at 9:25 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated a risk of caring for patients in a hall bed was that these patients did not have access to a call light. Further, they said hall beds were used in the past and the practice went away after a visit from the state health department; then during the COVID pandemic hall beds were put back in use and had been used ever since.

iii. On 1/2/24 at 11:46 a.m., an interview was conducted with charge nurse (RN) #5. RN #5 stated patients in hall beds did not have access to a nurse call light. They also said a risk to patients who received their care in a hall bed was the lack of access to a nurse call system to call for assistance when the patient needed to get up to prevent a fall. Further, they said access to a call light should have been available to all ED patients.

iv. On 12/27/23 at 9:17 a.m., an interview was conducted with nurse manager (Manager) #4. Manager #4 stated there were risks associated with caring for patients in hall beds without access to a call light. Specifically, they said patients could have vital signs or mental status changes, could fall, and could need assistance with personal care, toileting, or medications. Manager #4 stated ED staff wanted to ensure patients were kept safe.

v. On 12/28/23 at 7:40 a.m., an interview was conducted with medical director (Director) #1. Director #1 stated hall bed patients received the same standard of care as ED patients who had been cared for in a private ED room. They said hall bed patients had access to a nurse call light. Further, they said staff would never put a patient in a hallway if there was a room available for patient care.

This was in contrast to the observations and interviews conducted that revealed patients receiving care in the hall did not have access to a nurse call system.

This was also in contrast to the observation that revealed patients received care in hall beds when there were open rooms in the senior section of the ED.

2. The ED staff provided care to patients in hall beds in the absence of facility policies, procedures, and education to guide the staff in the care of the hall bed patient.

A. Document review

i. A facility policy or procedure for the care of hall bed patients in the ED was requested. An email from the manager of regulatory affairs (Manager) #9 stated the facility did not have a policy for hall beds.

ii. Facility tracking and trending on the use of hall beds in the ED was requested. An email from Manager #9 stated the facility was not currently tracking and trending the use of hall beds.

iii. A review of the medical record for Patient #6 revealed on 12/28/23 the patient arrived at the ED with a chief complaint of shortness of breath. They were placed in hall bed 32 at 4:39 p.m. At 4:51 p.m. triage was completed and the patient was assigned a triage level of ESI-2. According to the policy, ESI-2 patients were defined as Urgent Level 2 patients who were very ill and should have been seen as soon as possible.

iv. A review of the medical record for patient #8 revealed on 12/7/23 the patient arrived by ambulance at the ED with a chief complaint of weakness and respiratory distress. They were placed in hall bed 32 at 12:56 p.m. At 1:14 p.m. triage was completed and the patient was assigned a triage level of ESI-2.

B. Interviews

i. On 12/28/23 at 8:10 a.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated the decision to put a patient in the hall bed was made by the charge nurse. They said patients with low acuity who were not as sick as other patients should have been the patients placed in hall beds because the nurses were not able to monitor the hall beds as closely. They also said there was no written policy for guidance on patients receiving care in hall beds. Furthermore, RN #7 said the current process for when the ED rooms were full was that patients were put in hall beds because they were next in line. RN #7 stated staff did not want to put patients in hall beds, but if there was nowhere else to place a patient a higher acuity patient, such as a patient with chest pain, could have been placed in a hall bed.

RN #7 stated hall bed patients were at risk of delays in care because staff were looking for a place to provide care privately. (Cross reference A-0143) They said it was hard to conduct an accurate physical exam in the hallway because there was a lot of noise and they could not hear with the stethoscope. RN #7 stated the equipment required for attending to a patient in a hallway bed was not readily accessible, specifically citing the absence of immediate access to suction equipment, a resource typically available in dedicated patient rooms. Furthermore, they said the staff did their best for patients but the hall beds made it difficult to provide the best care to patients.

ii. On 1/2/24 at 11:46 a.m., an interview was conducted with ED charge nurse (RN) #5. They stated ideally staff would never use hall beds. RN #5 stated they did not know if there was a written policy for hall bed use. RN #5 also stated no special training was provided to nurses for the process of patients receiving care in hall beds.

RN #5 stated the charge nurse decided which patients went to the hall beds and those patients were lower acuity patients with an ESI-3 (stable, less acute patients whose condition required two or more resources for a disposition to be made). She said more acute ESI-1 (resuscitative/ emergent level one patients who were critically ill and required immediate physician evaluation and interventions) and ESI-2 (urgent level two patients who were very ill and should have been seen as soon as possible with concerns included but not limited to high-risk situations, new onset confusion, lethargy, or disorientation, and severe pain or distress) level patients should not have been put in a hall bed.

This was in contrast with the medical record reviews conducted that revealed ESI-2 level patients received care in hall beds.

iii. On 1/2/24 at 12:32 p.m., an interview was conducted with the director of emergency services (Director) #6. Director #6 stated they weren't sure how often hall beds were used. They said the ED staff pulled patients out of their rooms frequently to accommodate for incoming ambulance patients. However, they said there was no tracking and trending data collected related to hall bed use. Further, they said they would need to ask if there was an ED policy on hall bed use.

Director #6 stated staff caring for hall bed patients would have the same guidelines as patients located in an ED room. They said they would need to ask the ED educator if there was any special training for staff on the care of hall bed patients. Furthermore, they stated patients in hall beds got the same care as patients in a room.

This was in contrast to the interview with RN #7 who stated it was difficult to conduct assessments in the hallway due to the traffic and excessive noise.

iv. On 12/28/23 at 1:51 p.m., an interview was conducted with physician (MD) #8. MD #8 stated they would occasionally care for a patient in a hall bed when the ED was busy and full. They stated that sometimes it was the only option. MD #8 said the biggest limitation was not being able to remove a patient's clothing to do a thorough exam in the hallway. Additionally, they said history-taking interviews were somewhat limited due to a lack of privacy in the hallway.

v. On 12/28/23 at 7:40 a.m., an interview was conducted with medical director (Director) #1. Director #1 stated the use of hall beds was not regular or standard. They explained it was a "pop-off valve" used whenever space was not adequate to meet patient needs or volume. They said the charge nurse would decide if a patient needed to be placed in a hall bed.

Director #1 stated they did not think there was a policy about the use of hall beds. They said the criteria for placing a patient in a hall bed would have been a stable patient who would not need immediate intervention. They said the staff would not put a high-acuity patient in a hall bed.

This was in contrast to the review of medical records for patients #6 and #8 who were triaged as an ESI-2 and assigned to a hall bed location.