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Based on observation, interview and document review, it was determined for 1 of 11 (Pt #1) patients, the Hospital failed to ensure privacy was provided to all patients during the triage process.

Findings include:

1. On 05/23/2018 at approximately 10:25 AM, during the initial tour of the emergency department, E #2 (Triage Nurse) was seen collecting the data from Pt #1 in the triage area. The triage area was located at the corner of the emergency room and the waiting area. There were three patients sitting in the waiting area. Patient #1 was visible to patients in the waiting room. The information from Pt #1, "I have pain in my abdomen," was heard and observed around the triage area.

2. On 05/23/2018 at approximately 10:30 AM, E #2 (Triage Nurse) stated, "Yes, this is where I triage [open space near the waiting area]." Upon continuing the interview with E #1 (Charge RN-Registered Nurse) stated, "Yes, every patient must have privacy. So, initially we do the triaging in this area and then do a complete assessment in the triage room #1, #2, or #3. Unfortunately, this is the place where we do the initial triage of the patient."

3. On 05/24/2018 the Hospital presented a policy titled, "Compliance with HIPAA Privacy Regulations and Definitions," last revised 09/21/2016, that included, "3. Safeguards (Required Under HIPAA Privacy Regulation Section 164.530(c)(1)) ...The administrative and management team of each Presence Health ministry, in coordination with the ...b. Limit incidental use or disclosure of PHI [Protected Health Information] pursuant to an otherwise permitted or required use of disclosure."

Based on document review and interview it was determined that for 3 of 11 (Pt #8, Pt #9, and Pt #11) patient clinical records reviewed, the Hospital failed to ensure nursing re-assessments were done and documented while the patients were in the Emergency Department. This potentially affects the safety of patient while in the Emergency Department.

Findings include:

1. The clinical record review of Pt #8 was reviewed on May 24, 2018. Pt #8 was a 55 year old female admitted on 01/14/2018 to the Emergency Eepartment with the diagnoses of severe depression and bipolar disorder. The clinical record included the initial triage vital signs and nursing assessment that was documented upon admission at 3:20 PM. Pt #8's chief complaint was suicidal ideation and was placed on 1:1 [close observation within arm's reach] with a sitter. The physician's assessment and order for close observation were documented at 3:30 PM. Pt #8 was transferred to the behavioral health unit on 01/14/2018 at 8:34 PM. There was no re-assessment noted in the clinical record, for a duration of five (5) hours, from the period of admission until the transfer to another unit.

2. The clinical record review of Pt #9 was reviewed on 05/24/18. Pt #9 was a 56 year old female admitted on 01/30/2018 to the Emergency Department with the diagnoses of severe depression and bipolar disorder. The initial triage vital signs and nursing assessment were documented upon admission at 10:43 AM. Pt #9 was transferred to the Behavioral Health Unit on 01/30/2018 at 5:42 PM. There was no re-assessment documented in the clinical record, for a duration of seven (7) hours, from the period of admission until the transfer to another unit.

3. The clinical record of Pt #11 was reviewed on 05/24/18. Pt #11 was a 70 year old male admitted on 01/29/2018 to the Emergency Department with the diagnosis of severe recurrent major depression. The initial triage vital signs and nursing assessment were documented upon admission at 3:51 PM. Pt #11 was transferred to the Behavioral Health Unit on 01/29/18 at 9:18 PM. There was no re-assessment documented in the clinical record for a duration of five (5) hours twenty seven (27) minutes from the period of admission until the transfer to another unit.

4. On 05/24/2018 at approximately 10:30 AM, E #4 (Clinical Practice Specialist) stated, "It is essential to do an assessment and re-assessment. We want to make sure that things are not deteriorating. And especially before transferring the patient to the floor, re-assessments must be done."

5. On 05/25/2018 at approximately 11:10 AM, E #5 (Regional Director of Quality) stated, "We have a Hospital policy that states 'every shift' but, we do not have any policy that states about,'re-assessment' in the Emergency Department."

Based on document review and interview, it was determined that for 2 of 9 patients (Pts. #6 & 7), the Hospital failed to ensure a physician's order was in place with a 1:1 [close observation within arm's reach] sitter, as required.

Findings include:

1. The Hospital's policy titled, "Sitter Policy" (rev 3/1/16) required, "Procedure: The Hospital will provide sitters for behaviors identified... with a physician order.

2. The clinical record for Pt. #6 was reviewed on 5/24/18. Pt. #6 was a 63 year old male who presented to the Emergency Department (ED) on 3/31/18 with a diagnosis of acute alcohol intoxication. The clinical record indicated that patient #6 had a 1:1 sitter at the bedside, however there was no physician order for the sitter.

3. The clinical record for Pt. #7 was reviewed on 5/24/18. Pt. #7 was a 22 year old female who presented to the Emergency Department (ED) on 3/31/18 with diagnoses of behavioral agitation and acute alcohol intoxication. The clinical record indicated that Pt. #7 had a 1:1 sitter at the bedside; however, there was no physician's order for the sitter.

4. The above findings were discussed with the Clinical Practice Specialist (E #4), during an interview on 5/24/18, at approximately 10:30 AM. E #4 stated, "Absolutely there should be an order."