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Based on observation, record review and interview, the facility failed to ensure care in a safe setting by not ensuring 3 of 3 emergency room patients had the call bell/light within reach. (Patient ID#s 5, 6 and 7).

Findings include:
Observation in the emergency department on 10/6/23 at 10:17 AM showed patients (ID#s 5, 6, and 7) in the department's critical rooms without call bell/light within reach.

Interview with department manager (ID# 56) at the time of observation confirmed the above findings and stated that the call bell/light should be placed within reach for all patients.

Record review of facility policy titled "Patient Rights" dated 08/30/2023 showed the following information:

III Procedure
A. Inform each patient, both inpatient or outpatient, or when appropriate, the patient's LAR of the patient's rights. Whenever possible, provide a copy of the patient rights prior to starting or stopping care, treatment or services.

B. Display the notice of patient rights with a prominent and conspicuous posting in a public area available to patients, visitors, medical, employees and other staff.

C. Operationalize this policy and procedure through supporting processes and practices.

Record review of facility document titled "Your rights and other important information for Houston Methodist patients" showed the following information:

PATIENT RIGHTS
You have the Right to:
-Receive care in a safe setting.

Record review of facility policy titled "Patient Admission Process and Documentation" dated 9/12/22 showed the following information:
PROCEDURE
4. Explain hospital policies and services on the following subjects:
c. Use of telephone. Television and call light system.

Record review of facility orientation and training packet titled "Welcome to Houston Methodist Willowbrook Emergency Services" showed the following :

Daily Expectations
-Patient's call light must remain within reach.