HospitalInspections.org

Based on observation, staff interviews, and administrative document review, the hospital failed to adhere to professional standards of practice for Emergency Departments (ED) when two of two patients (Patient 4 and Patient 5) were treated and dispositioned in the hallway of the ED. Patient confidentiality and privacy were not protected in this area of the ED. These failures resulted in the potential loss of confidentiality and privacy and could negatively affect the quality of care for all patients seen in the ED.

Findings:

On 5/22/12 at 10 a.m., during an observation, the ED at Campus 2 was toured. The ED treatment area was separated from the patient lobby/registration area by a door controlled for limited access. The ED treatment area consisted of a nurse's station, triage examination room and ten treatment bays. Seven ED treatment bays (ED Bay 1, ED Bay 2 ... ED Bay 7) were configured on one side of the treatment area and separated by a hallway from the remaining three ED bays (ED Bay 8 ... ED Bay 10) on the other side of the hall. ED Bay 1 through ED Bay 10 were appropriately equipped to assess and treat patients (for example, patient examination bed, medical devices to obtain blood pressure, otoscopes/ophthalmoscope [device to examine ears/eyes], oxygen) and a privacy curtain .

The following numbers were observed placed on the hallway wall closest to ED Bay 1: 11, 12, 13, and 14 and were called Station 11, Station 12, Station 13, Station 14 according to the ED Director. Plastic chairs were placed under each corresponding number (11, 12, 13, 14) along the wall in the hallway. There was no other medical equipment or devices or privacy curtain in the hallway for Stations 11, 12, 13, 14. During the tour, two patients (Patients 4 and 5) were located in Stations 11 and 12. One patient was sitting hunched over with his head in his lap in Station 11 and the other patient was lying on a gurney (specialized patient bed with wheels) located at Station 12.

On 5/22/12 at 10:15 a.m., during an interview with the Registered Nurse, Staff 18, explained the process of patient flow in the ED treatment area and the use of Stations 11 through 14. Staff 18 confirmed he was the assigned registered nurse for Patient 4 in Station 11. Staff 18 explained that for patients presenting with uncomplicated symptoms (for example, upper respiratory illness, slight fever, minor sprains and abrasions), the patient would be seen in the triage room and assigned a low emergency severity index. Staff 18 stated that Patient 4 was placed at Station 11 because he was a re-check from an ED visit the day before (5/21/12).

Staff 18 stated that if all rooms (ED bays 1 through 10) were occupied, low acuity patients would be placed in the chairs associated with Stations 11, 12, 13, 14. In general these types of patients would be given discharge instructions from Stations 11, 12, 13, 14. Staff 18 explained that occasionally physical examination and treatment of the patient would occur in Station 11, 12, 13, 14, but that would be rare. In other words, Staff 18 explained, a patient would be asked to move to Stations 11 through 14 in order to receive final discharge instructions and treatment plan. Staff 18 confirmed that no accommodations were made in order to safeguard confidentiality, privacy and dignity while patients were placed at Stations 11, 12, 13, 14. Staff 18 confirmed that medical equipment occasionally would be carried to Stations 11 through 14 in order to complete the ED treatment process. (For example, blood pressure cuffs or devices, glucometer and/or otoscopes).

On 5/22/12 at 11 a.m., during an interview, the ED Director (Staff 19) discussed the patient flow in the ED of Campus 2. The ED Director described a Rapid Medical Screening (RMS) patient flow process that had been in effect for approximately three or more years. The ED Director explained the RMS process was geared to "treat and street" patients with uncomplicated symptoms (for example, mild upper respiratory illnesses, minor skin cuts and bruises, minor fevers). These types of patients would be triaged and then placed in ED bays 1 through 10 and when ready for discharge would be placed in the chairs in the hallways designated Stations 11 through 14. The ED Director confirmed no accommodations were made in order to protect patient confidentiality, privacy and dignity while awaiting disposition in Stations 11 through 14. The ED Director explained that staff were trained to request permission from the patient to be placed in Stations 11 through 14. The ED Director acknowledged that on occasion, when the ED was very busy, patients would be placed in Stations 11 through 14 and have part of their physical assessment and treatment in the hallway. When asked whether the hallway and Stations 11 through 14 were designed for the assessment, treatment and discharge of patients, the ED Director did not comment. The ED Director stated there was no hospital policy and procedure providing guidance on "treat and street" or the use of Stations 11 through 14. The ED Director confirmed Stations 11 through 14 were not used for "parking" patients brought in by ambulance.

On 5/22/12 at 1:20 p.m., during an interview, Staff 20 (RN) stated he was the assigned Charge Nurse for the ED on 5/22/12. Staff 20 stated Patient 5 was placed at Station 12 after an order to place another patient in the assigned ED Bay. Staff 20 confirmed that Stations 11 through 14 were used for patients ready to be discharged and were stable and with uncomplicated symptoms. Staff 20 acknowledged that occasionally Stations 11 through 14 were used for patient assessment and treatment as well as discharge. Staff 20 confirmed no complicated patients were placed in Stations 11 through 14. Staff 20 confirmed patients brought in by ambulance were never placed in Stations 11 through 14.

The clinical record for Patient 4 who was in Station 11 was reviewed. The patient was seen in the ED Campus 2 on 5/21/12 with pain, redness and selling of the top of right foot. The diagnosis was cellulite (infection of the skin), treated with antibiotics and asked to return on 5/22/12. On 5/22/12 Patient 4 was placed in Station 11 on a chair in the ED hallway to be seen by the ED physician. The ED physician determined the patient required further assessment and treatment and placed in ED Bay 9. After receiving additional treatment, Patient 4 was discharged home from ED Bay 2.

The clinical record for Patient 5 was reviewed. Patient 5 was admitted to ED Bay 1 with symptoms of alcohol abuse "and not feeling well" at approximately 5:30 a.m. on 5/22/12. At approximately 9:45 a.m. on 5/22/12, Patient 5 was placed in Station 12 on a gurney to make room for another patient with symptoms of seizures. The physician had documented that Patient 5 was stable for discharge to home.

On 5/24/12 the hospital's Patient Rights policy (Number 1000.16.09) was reviewed. On page three under Privacy the policy stated "... The hospital respects the rights of patients to: ... b. Receive healthcare services in surroundings designed to provide reasonable visual and auditory privacy ... c. Expect that any discussion or consultation involving the patient's case will be conducted discreetly."

On 5/24/12 the Office of Civil Rights (OCR) HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule under 45 CFR 165.502(a)(1)(iii) was reviewed. Under " How the Rule Works: Reasonable Safeguards " the rule indicated " A covered entity must have in place appropriate administrative, technical, and physical safeguards that protect against uses and disclosures not permitted by the Privacy Rule, as well as that limit incidental uses or disclosures ... Covered entities should also take into account the potential effects on patient care ... " Under " Minimum Necessary " the Rule indicated " Covered entities also must implement reasonable minimum necessary policies and procedures that limit how much protected health information is used, disclosed, and requested for certain purposes. These minimum necessary policies and procedures also reasonably must limit who within the entity has access to protected health information, and under what conditions, based on job responsibilities and the nature of the business ... " As an example of reasonable safeguards under FAQ (Frequently Asked Questions) the rule indicated " ... In an area where multiple patient-staff communications routinely occur, use of cubicles, dividers, shields, curtains or similar barriers may constitute a reasonable safeguard. For example, a large common intake area may reasonably use cubicles or shield-type dividers, rather than separate rooms, or providers could add curtains or screens to areas where discussions often occur between doctors and patients or among professionals treating the patient ... "

Based on observation, staff interviews, and administrative document review, the hospital failed to adhere to professional standards of practice for Emergency Departments (ED) when two of two patients (Patient 4 and Patient 5) were treated and dispositioned in the hallway of the ED. Patient confidentiality and privacy were not protected in this area of the ED. These failures resulted in the potential loss of confidentiality and privacy and could negatively affect the quality of care for all patients seen in the ED.

Findings:

On 5/22/12 at 10 a.m., during an observation, the ED at Campus 2 was toured. The ED treatment area was separated from the patient lobby/registration area by a door controlled for limited access. The ED treatment area consisted of a nurse's station, triage examination room and ten treatment bays. Seven ED treatment bays (ED Bay 1, ED Bay 2 ... ED Bay 7) were configured on one side of the treatment area and separated by a hallway from the remaining three ED bays (ED Bay 8 ... ED Bay 10) on the other side of the hall. ED Bay 1 through ED Bay 10 were appropriately equipped to assess and treat patients (for example, patient examination bed, medical devices to obtain blood pressure, otoscopes/ophthalmoscope [device to examine ears/eyes], oxygen) and a privacy curtain .

The following numbers were observed placed on the hallway wall closest to ED Bay 1: 11, 12, 13, and 14 and were called Station 11, Station 12, Station 13, Station 14 according to the ED Director. Plastic chairs were placed under each corresponding number (11, 12, 13, 14) along the wall in the hallway. There was no other medical equipment or devices or privacy curtain in the hallway for Stations 11, 12, 13, 14. During the tour, two patients (Patients 4 and 5) were located in Stations 11 and 12. One patient was sitting hunched over with his head in his lap in Station 11 and the other patient was lying on a gurney (specialized patient bed with wheels) located at Station 12.

On 5/22/12 at 10:15 a.m., during an interview with the Registered Nurse, Staff 18, explained the process of patient flow in the ED treatment area and the use of Stations 11 through 14. Staff 18 confirmed he was the assigned registered nurse for Patient 4 in Station 11. Staff 18 explained that for patients presenting with uncomplicated symptoms (for example, upper respiratory illness, slight fever, minor sprains and abrasions), the patient would be seen in the triage room and assigned a low emergency severity index. Staff 18 stated that Patient 4 was placed at Station 11 because he was a re-check from an ED visit the day before (5/21/12).

Staff 18 stated that if all rooms (ED bays 1 through 10) were occupied, low acuity patients would be placed in the chairs associated with Stations 11, 12, 13, 14. In general these types of patients would be given discharge instructions from Stations 11, 12, 13, 14. Staff 18 explained that occasionally physical examination and treatment of the patient would occur in Station 11, 12, 13, 14, but that would be rare. In other words, Staff 18 explained, a patient would be asked to move to Stations 11 through 14 in order to receive final discharge instructions and treatment plan. Staff 18 confirmed that no accommodations were made in order to safeguard confidentiality, privacy and dignity while patients were placed at Stations 11, 12, 13, 14. Staff 18 confirmed that medical equipment occasionally would be carried to Stations 11 through 14 in order to complete the ED treatment process. (For example, blood pressure cuffs or devices, glucometer and/or otoscopes).

On 5/22/12 at 11 a.m., during an interview, the ED Director (Staff 19) discussed the patient flow in the ED of Campus 2. The ED Director described a Rapid Medical Screening (RMS) patient flow process that had been in effect for approximately three or more years. The ED Director explained the RMS process was geared to "treat and street" patients with uncomplicated symptoms (for example, mild upper respiratory illnesses, minor skin cuts and bruises, minor fevers). These types of patients would be triaged and then placed in ED bays 1 through 10 and when ready for discharge would be placed in the chairs in the hallways designated Stations 11 through 14. The ED Director confirmed no accommodations were made in order to protect patient confidentiality, privacy and dignity while awaiting disposition in Stations 11 through 14. The ED Director explained that staff were trained to request permission from the patient to be placed in Stations 11 through 14. The ED Director acknowledged that on occasion, when the ED was very busy, patients would be placed in Stations 11 through 14 and have part of their physical assessment and treatment in the hallway. When asked whether the hallway and Stations 11 through 14 were designed for the assessment, treatment and discharge of patients, the ED Director did not comment. The ED Director stated there was no hospital policy and procedure providing guidance on "treat and street" or the use of Stations 11 through 14. The ED Director confirmed Stations 11 through 14 were not used for "parking" patients brought in by ambulance.

On 5/22/12 at 1:20 p.m., during an interview, Staff 20 (RN) stated he was the assigned Charge Nurse for the ED on 5/22/12. Staff 20 stated Patient 5 was placed at Station 12 after an order to place another patient in the assigned ED Bay. Staff 20 confirmed that Stations 11 through 14 were used for patients ready to be discharged and were stable and with uncomplicated symptoms. Staff 20 acknowledged that occasionally Stations 11 through 14 were used for patient assessment and treatment as well as discharge. Staff 20 confirmed no complicated patients were placed in Stations 11 through 14. Staff 20 confirmed patients brought in by ambulance were never placed in Stations 11 through 14.

The clinical record for Patient 4 who was in Station 11 was reviewed. The patient was seen in the ED Campus 2 on 5/21/12 with pain, redness and selling of the top of right foot. The diagnosis was cellulite (infection of the skin), treated with antibiotics and asked to return on 5/22/12. On 5/22/12 Patient 4 was placed in Station 11 on a chair in the ED hallway to be seen by the ED physician. The ED physician determined the patient required further assessment and treatment and placed in ED Bay 9. After receiving additional treatment, Patient 4 was discharged home from ED Bay 2.

The clinical record for Patient 5 was reviewed. Patient 5 was admitted to ED Bay 1 with symptoms of alcohol abuse "and not feeling well" at approximately 5:30 a.m. on 5/22/12. At approximately 9:45 a.m. on 5/22/12, Patient 5 was placed in Station 12 on a gurney to make room for another patient with symptoms of seizures. The physician had documented that Patient 5 was stable for discharge to home.

On 5/24/12 the hospital's Patient Rights policy (Number 1000.16.09) was reviewed. On page three under Privacy the policy stated "... The hospital respects the rights of patients to: ... b. Receive healthcare services in surroundings designed to provide reasonable visual and auditory privacy ... c. Expect that any discussion or consultation involving the patient's case will be conducted discreetly."

On 5/24/12 the Office of Civil Rights (OCR) HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule under 45 CFR 165.502(a)(1)(iii) was reviewed. Under " How the Rule Works: Reasonable Safeguards " the rule indicated " A covered entity must have in place appropriate administrative, technical, and physical safeguards that protect against uses and disclosures not permitted by the Privacy Rule, as well as that limit incidental uses or disclosures ... Covered entities should also take into account the potential effects on patient care ... " Under " Minimum Necessary " the Rule indicated " Covered entities also must implement reasonable minimum necessary policies and procedures that limit how much protected health information is used, disclosed, and requested for certain purposes. These minimum necessary policies and procedures also reasonably must limit who within the entity has acc