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Based on observations, interviews and record reviews, the facility failed to ensure the emergency department's environment was maintained to assure the safety and well-being of patients using the waiting area facilities.

Specifically, the Emergency Department's (ED) bathrooms in the waiting area of the emergency department did not have an emergency communication system for patient safety in the event of a medical need, medical event, and/or emergency. These bathrooms are utilized by admitted patient's that are in overflow during high capacity times; pending a bed and/or further placement.

This failure created the potential for serious injury, harm, and the possibility for delay in care in the event of a fall or medical deterioration event.

Findings included:

Review of the intake information for complaint TX00550193, dated 6/28/25, revealed the following, in part:
Patient #1 alleged she was, "left alone in a hospital bathroom after being sedated with morphine and a nerve block, then forced to wobble back down the hallway to my stretcher without assistance."

Observations conducted on 9/4/25 at 12:10 PM with Staff #2, and Staff #4 present revealed the ED's waiting room bathrooms; Male, Female, and a single use bathroom did not have an emergency communication system in the event of a medical need, and/or an emergency event of a patient. Further observations revealed these bathroom facilities were the closest bathrooms accessible to patients placed in overflow/waiting placement during high capacity times.

Interview on 9/4/25 at 12:15 PM, with Staff #4 confirmed the bathrooms did not have an emergency call system, stating the bathroom facilities were "public use." Further interview with Staff #4 confirmed admitted patients would be held in the emergency waiting area during high capacity times as an overflow area when patient treatment areas were full. The waiting area was also used by patients pending discharge during high capacity times.

Interview on 9/4/25 at 12: 17 PM, with Staff #2 indicated the issue of no communication system in the bathrooms had been reviewed previously, and the facility would ensure it is addressed.

Review of the facility's Policy, No. 9.06 titled, Patient Rights and Responsibilities, effective 12/17/2021 indicated in part; In accordance with all applicable federal and state laws and regulations, [the facility] respects, protects and promotes the patient's right to: B. Receive care that is in a safe setting.......