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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0143 - Standard: Patient Rights: Personal Privacy. The patient has the right to personal privacy. The facility failed to ensure the personal privacy of patients who received care while placed in hall beds located in the emergency department's corridors.

A-0144 - Standard: Patient Rights: Care in a Safe Setting. The patient has the right to receive care in a safe setting. The facility failed to ensure the safety of hall bed patients by neglecting to provide a nurse-call signal system at every hall bed.

Based on observation, interviews and record review, the facility failed to have a process in place to ensure the personal privacy of patients who received care while placed in hall beds located in the Emergency Department (ED) corridors.

This failure created instances in which patients were asked personal questions, received physical assessments, nursing care, education and discharge instructions while in open corridors within the Emergency Department without processes in place to ensure their privacy.

FINDINGS

POLICY

According to Patient Rights and Responsibilities, when you are a patient you have the right to receive quality care that is considerate and respectful of your dignity, personal values, beliefs, and life philosophy and to be interviewed, examined, and treated in a safe setting that provides personal privacy.

1. The ED staff provided care to patients in hall beds without ensuring the use of screens, curtains, or other measures to ensure patients' personal privacy and confidentiality of sensitive patient-staff conversations.

a) On 01/04/17 at 1:20 p.m. a tour of the ED was conducted. Upon entry to the ED, observation revealed Patient #11 placed in a hall bed in the main corridor of the ED against a wall across from the behavioral health rooms. Patient #11 was observed in hall bed 4 in street clothes sleeping on a stretcher. Visitors for a different patient were standing approximately 20 feet from Patient #11 who's identification band was visible which included name and date of birth. Review of Patient #11's medical record revealed s/he was admitted to hall bed 4 at 9:57 a.m. where nursing assessments were performed at 10:11 a.m. Patient #11 remained in hall bed 4 from 9:57 a.m. until 1:30 p.m., 3.5 hours in total. No privacy screen or curtain was observed near Patient #11.

b) During the same time an interview was conducted with a Security Officer (SO #1). SO #1 stated when the 3 behavioral health (BH) beds were full hall beds 4 and 5 located in the corridor across from the BH area were used for BH patients to allow for observation by the same security officer. SO #1 confirmed hall beds 1-3 were used for medical patients and not routinely observed by security officers.

c) On 01/04/17 at 1:34 p.m. an interview was conducted with a ED Registered Nurse (RN #3). RN #3 stated hall beds were used in emergent situations, when all regular beds were full or when a patient required monitoring and was unsafe to be left in the lobby. RN #3 elaborated a patient who required special monitoring due to age or mental capacity would not be placed in a private room but would be placed in a hall bed across from the nurse's station to allow multiple staff members to observe the patient and any hall bed patient could ask any staff member walking by for assistance when needed. Further stated by RN #3, any patient who was incontinent would not be cleaned in the hall but would be taken to an available room to be cleaned up.

d) An interview was conducted with ED RN #5 on 01/04/17 at 1:47 p.m. RN #5 confirmed hall beds 1-3 were used for medical patients and hall beds 4-5 were used for BH patients so that security could observe them. RN #5 stated s/he had performed blood draws and intravenous (IV) catheter placement on patients in hall beds. RN #5 stated once a patient was moved to their assigned bed a focused physical assessment would be performed.

e) On 01/04/17 at 3:12 p.m. an interview was conducted with the ED Manager (RN #6). RN #6 stated hall beds were used at the discretion of the charge nurse and primarily for BH patients so that security could monitor them with medical patients placed in hall beds 1-3 across from the nurse's station when close monitoring was required. RN #6 confirmed when Patient Access Representatives received (registered) a patient, verification of name and date of birth was conducted and this included patients admitted to hall beds. Upon further discussion, RN #6 stated invasive procedures and personal care were not performed in a hall bed, instead a private bed was located to perform the task then the patient was returned to the ED corridor. RN #6 added, the facility made efforts to maintain the privacy of patients in hall beds by ensuring visitors remained in the lobby or patient rooms and were not allowed to stand in the ED corridor.

f) During an interview with the Director of ED (Director #8) on 01/05/17 at 10:10 a.m. Director #8 confirmed the use of hall beds when census was high for patients whose privacy could be maintained while in a hall bed. Director #8 stated privacy was maintained by speaking in low voices and avoiding the performance of invasive examinations in hall beds although IV insertions and focused assessments had been performed on patients in hall beds. Director #8 added, the use of hall beds was not ideal.

g) An interview was conducted with the Chief Nursing Officer (CNO #7) on 01/04/17 at 4:17 p.m. CNO #7 stated privacy for patients in hall beds was maintained by avoiding undressing them in front of other people or moving the patient to a private area to change then return them to the corridor. CNO #7 verbalized s/he had knowledge of federal and state regulations on patient privacy and believed it was appropriate to move a patient from a room to a hall bed for short periods of time even though the hall beds did not meet the regulations for privacy.

h) On 01/05/17 at 9:17 a.m. an interview was conducted with the Chief Operating Officer (COO #9). COO #9 stated s/he did not believe there was a policy on the use of hall beds in the ED and the determination for use was left up to the nurses who were trusted to know which patients were appropriate for placement in hall beds. COO #9 further stated it was not appropriate for patients to be assessed while in hall beds but was unsure how nursing staff addressed the privacy needs of patients in hall beds. COO #9 added s/he did not believe patient safety, privacy or quality of care was jeopardized during the use of hall beds.

Based on observations, interviews and document review, the facility failed to ensure the safety of hall bed patients by neglecting to provide a call system for hall beds.

The failure created the potential for an increased risk to patient safety and negative patient outcomes.

FINDINGS

POLICY

According to Patient Rights and Responsibilities, when you are a patient you have the right to receive quality care that is considerate and respectful of your dignity, personal values, beliefs, and life philosophy and to be interviewed, examined, and treated in a safe setting that provides personal privacy.

Additionally, Assigning Care of Patients, states assignments for the delivery of patient care includes consideration of the geographical location of individual patients to allow visual monitoring of patients and effective use of nurses' time.

1. The facility failed to provide a call system for all hall beds in the Emergency Department (ED) for patient use and safety.

a) A tour of the facility was conducted on 01/03/17 at 10:40 a.m. with the Chief Nursing Officer (CNO #7). Upon arriving in the Emergency Department the ED Manager (Registered Nurse, RN #6) and the ED Clinical Director (Director #8) accompanied the surveyors.

RN #6 explained the ED was divided into 6 zones with each nurse assigned to care for 3-5 patients within a given zone and were divided as follows:

Zone 1 - rooms 3, 4, 5 and Trauma 1;
Zone 2 - rooms 6, 7, 8 and Trauma 2;
Zone 3 - rooms 9, 10, 11 with Behavioral Health room 28;
Zone 4 - rooms 12, 13, 14 with Behavioral Health room 29;
Zone 5 - rooms 15, 16, 17 with Behavioral Health room 30;
Zone 6 - rooms 18, 22, 23 and 24.

Additionally, RN #6 identified the Fast Track area with rooms 25, 26, and 27 was open 11 a.m. to 11 p.m. only. During times of high census, RN #6 stated Zone 7 which included rooms 19, 20, and 21 could be opened to accommodate increased patient volume.

b) On 01/04/17 at 1:20 p.m., a second tour of the ED was conducted at which time Patient #11 was observed on a bed along the wall across from the behavioral health rooms (28, 29 and 30) with a sign posted above the bed labeled Hall Bed 4. Observations of the ED revealed call systems were not present at 5 of the 5 hall beds (Hall Beds 1, 2, 3, 4, and 5).

In the central ED across from the nurse's station 3 patient beds were observed lined against the wall. These beds were labeled Hall Bed 1, Hall Bed 2 and Hall Bed 3. At the far end of the hall past the nurse's station and across from the behavioral health rooms were 2 additional beds lined against the wall labeled Hall Bed 4 and Hall Bed 5. All beds had a fitted sheet on them.

Continued observations made in the ED revealed 4 of 5 Fast Track rooms, 7 bays, 3 private rooms and 1 Trauma Room were available for Patient #11 to be placed in. Review of Patient #11's medical record revealed s/he was admitted to hall bed 4 from 9:57 a.m. until 1:30 p.m., 3.5 hours in total.

c) At 1:25 p.m. an interview was conducted with a Security Officer (SO #1) located at the door of the behavioral health rooms. SO #1 stated when the 3 behavioral health (BH) beds were full hall beds 4 and 5 situated in the corridor across from the BH area were used for BH patients to allow for observation by the same security officer. SO #1 confirmed hall beds 1-3 were used for medical patients and not routinely observed by security officers. SO #1 added, when a patient in the BH area required the use of the restroom security officers were expected to call for assistance from a second security officer located in other areas of the facility to prevent leaving BH patients unattended. There were no call lights located in the 3 BH rooms nor the hall beds assigned to the BH area.

d) An interview was conducted with the ED Nurse Educator (RN #4) on 01/04/17 at 1:42 p.m. RN #4 stated there was no official system for hall bed patients to contact staff for assistance but there was typically someone in the area to assist or the unit secretary could be asked to monitor a hall bed patient from their position in the nurse's station.

e) A second interview was conducted with the ED Manager (RN #6) on 01/04/17 at 3:12 p.m. in a facility conference room. RN #6 confirmed hall beds had been used to decrease wait times in the lobby and to accommodate the increased volume of ED visits. According to RN #6, there was no policy which provided guidance on the type of patient who may be placed in a hall bed and the choice was left to the discretion of the charge nurse. RN #6 described instances when patients arrived by ambulance and had to be placed in a hall bed.

During continued discussion with RN #6 s/he stated when ED census increased in conflict with normal staffing patterns, patients were placed in hall beds instead of Zone 7 beds due to its de-centralized location which did not provide for continuous visual monitoring of patients. RN #6 confirmed there was no call light system available to the hall bed patients, however, the presence of staff within the central ED afforded patients the ability to stop any staff member walking by to obtain assistance and further verified the placement of security officers in the BH area was due to the lack of call lights in rooms 28, 29 and 30. RN #6 stipulated the maximum number of patients a security officer could monitor in the BH area was 3 which was in contrast to the 4 patients seen monitored by the security officer in the BH area and hall bed 4.

f) On 01/05/17 at 9:24 a.m. an interview was conducted with the Chief Operating Officer (COO #9). According to COO #9 the use of hall beds was not a regular practice since s/he performed leadership rounds approximately 3 times per week during multiple shifts and had rarely seen them in use. With regard to Patient #11 observed in a hall bed instead of an open bed, COO #9 stated it could not be assumed the empty beds observed were available when Patient #11 arrived at the ED or that the empty beds were cleaned and ready for patient placement. COO #9 further stated s/he did not believe the safety of patients was jeopardized by the use of hall beds.

g) During a second interview with Director #8 on 01/05/17 at 10:10 a.m. s/he stated 42 patients had visited the ED for treatment between the hours of 7:06 a.m. and 12:08 p.m. on 01/04/17. Director #8 stated there were times when there were no rooms available and patients "spill over" to hall beds and times when every bed was full patients may be moved from a room into a hall bed. Director #8 stated the Fast Track area was not open and staffed for patients when Patient #11 arrived at the ED and the patient required direct security observation so s/he was placed in a hall bed near the security officer. Director #8 further stated patients in hall beds must verbally call for assistance if needed.

h) The event logs for ED patients seen in the ED on 01/04/17 from 7:00 a.m. until 2:00 p.m. was requested for review. Review of the requested event logs revealed 5 regular room beds and 3 Fast Track rooms were available for use when Patient #11 was admitted at 9:57 a.m. All 8 available rooms had call light systems for patient safety.

Further review of the provided event logs showed 22 beds with call lights came available during Patient #11's 3.5 hour stay in hall bed 4. As example, room 18 was occupied by a patient from 7:16 a.m. until 9:53 a.m. A new patient was admitted to room 18 at 9:58 a.m. and discharged at 11:48 a.m. Ten minutes later at 11:58 a.m. a third patient was admitted to room 18 while Patient #11 remained in hall bed 4 from 9:57 a.m. until 1:30 p.m. without a call light for safety.

In addition, room 5 had a patient discharge at 10:54 a.m. and a second patient was not admitted to room 5 until 11:10 a.m. and subsequently discharged at 11:29 a.m. followed by the admission of a third patient at 11:47 a.m. This presented 2 opportunities for Patient #11 to be transferred from Hall Bed 4 to room 5 where privacy and a call light system was available for safety.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.41, PHYSICAL ENVIRONMENT, was out of compliance.

A-0725 - Standard: Complexity of Facilities: The extent and complexity of facilities must be determined by the services offered. The facility failed to ensure the Emergency Department was designed to accommodate the volume of patients who presented to and were treated in the Emergency Department (ED).

Based on observations, interviews and document review the facility failed to ensure the Emergency Department (ED) was designed to accommodate the volume of patients who presented to and were treated in the Emergency Department.

This failure created the potential for an increased risk to patient safety related to patients receiving treatment in the emergency department corridors.

FINDINGS:

POLICY

According to Assigning Care of Patients, assignments for the delivery of patient care are based on the following considerations and will be made by the nurse in charge: Geographical location of individual patients to allow appropriate visual monitoring of patients and effective use of nurses' time.

1. The facility failed to ensure the Emergency Department was designed and utilized to accommodate the volume of patients who presented to and were treated in the Emergency Department (ED).

a) On 01/04/17 at 1:20 p.m. a second tour of the ED was conducted. Upon entry to the ED, observations revealed 3 patient beds across from the nurse's station lined against the wall. These beds were labeled Hall Bed 1, Hall Bed 2 and Hall Bed 3. At the far end of the hall past the nurse's station and across from the behavioral health rooms were 2 additional beds lined against the wall labeled Hall Bed 4 and Hall Bed 5. All beds had a fitted sheet on them.

Observation revealed Patient #11 in hall bed 4 wearing street clothes sleeping on a stretcher. Review of Patient #11's medical record revealed s/he was admitted to hall bed 4 at 9:57 a.m. and remained in hall bed 4 until 1:30 p.m., 3.5 hours in total.

Continued observations made throughout the ED revealed 4 of 5 fast track rooms, 7 bays, 3 private rooms and 1 trauma room were vacant of patients with fitted sheets and folded gowns on beds.

b) On 01/04/17 at 1:25 p.m. an interview was conducted with a Security Officer (SO #1) located at the door of the behavioral health rooms. SO #1 stated when the 3 behavioral health (BH) beds were full hall beds 4 and 5 situated in the corridor across from the BH area were used for BH patients to allow for observation by the same security officer.

c) On 01/03/17 medical record review for Patient #4 was completed. Patient #4's medical record revealed on 01/15/16 at 7:15 p.m. Patient #4 was admitted to hall bed 1. Patient #4 was moved to Room 7 at 7:34 p.m. S/he remained in Room 7 until 9:19 p.m. at which time s/he was placed into hall bed 2. Patient #4 was in a hall bed for 45 minutes of his/her ED visit.

d) At 1:34 p.m. on 01/04/17 an interview was conducted with an ED Registered Nurse (RN #3). RN #3 stated hall beds were used in emergent situations, when all regular beds were full or when a patient required monitoring and was unsafe to be left in the lobby. RN #3 stated a patient who required special monitoring due to age or mental capacity would not be placed in a private room but would be placed in a hall bed across from the nurse's station to allow multiple staff members to observe the patient and any hall bed patient could ask any staff member walking by for assistance when needed.

e) During an initial tour of the ED on 01/03/17 at 11:33 a.m. RN #6 explained the ED was divided into 6 zones with each nurse assigned to care for 3-5 patients within a given zone and were divided as follows:

Zone 1 - rooms 3, 4, 5 and Trauma 1
Zone 2 - rooms 6, 7, 8 and Trauma 2
Zone 3 - rooms 9, 10, 11 with Behavioral Health room 28
Zone 4 - rooms 12, 13, 14 with Behavioral Health room 29
Zone 5 - rooms 15, 16, 17 with Behavioral Health room 30
Zone 6 - rooms 18, 22, 23 and 24

Additionally, RN #6 identified the Fast Track area with rooms 25, 26, and 27 was open 11 a.m. to 11 p.m. only. During times of high census, RN #6 stated Zone 7 which included rooms 19, 20, and 21 could be opened to accommodate increased patient volume.

During a second interview with RN #6 conducted on 01/04/17 at 3:12 p.m. s/he stated hall beds were used at the discretion of the charge nurse. Medical patients were placed in hall beds 1-3 across from the nurse's station when close monitoring was required. BH patients were monitored in hall beds 4 and 5. RN #6 confirmed hall beds had been used to decrease wait times in the lobby. S/he further stated the use of hall beds occurred on a regular basis. According to RN #6, there was no policy which provided guidance on the type of patient who could be placed in a hall bed. RN #6 described instances when patients arrived by ambulance and had been placed in a hall bed.

During the same interview RN #6 went on to state when ED census increased, patients were placed in hall beds instead of opening Zone 7 due to lack of staff coverage and geographical location of Zone 7. S/he stated due to Zone 7's de-centralized location nurses could not put patients in Zone 7 if they needed continuous monitoring; the patient would be placed in a hall bed. RN #6 stated s/he could contact the facility's house supervisor to discuss the need for additional staff; however, 99% of the time the facility had no additional staff to assist the ED.

RN #6 stated, during the interview conducted on 01/04/17, the facility never went on diversion (closure of ED for ambulance admissions only). S/he stated there were specific criteria needed if s/he felt the facility needed to be placed on diversion. RN #6 explained it would require a chain of command escalation and was not a decision s/he would make independently. S/he could not remember a time when the hospital went on diversion.

f) During an interview with the Director of ED (Director #8) on 01/05/17 at 10:10 a.m. s/he confirmed the use of hall beds when patient census was high. S/he stated the use of hall beds occurred on a weekly basis. Director #8 stated the ED staffing was based on historical patient census. S/he stated although the facility did not have a process to review how often hall beds were used, if the daily patient census was over 130 patients it would be assumed hall beds were used. S/he went on to state when the ED reported being full it meant every bed including hall beds were being used.

During the same interview on 01/05/07, Director #8 stated on 01/04/17, 42 patients had visited the ED for treatment between the hours of 7:06 a.m. and 12:08 p.m. Director #8 stated the Fast Track area was not opened and Zone 7 was not staffed for patients when Patient #11 arrived at the ED at 9:57 a.m. S/he stated Patient #11 required direct security observation so s/he was placed in a hall bed near the security officer.

Director #8 stated the use of hall beds was not ideal for the staff or for the patients. S/he stated the RNs used scripting when a patient was asked to move into a hall bed as an explanation for the reasons care was received in the uncomfortable accommodations of a hall bed.

g) During an interview on 01/05/17 at 9:08 a.m. Chief Nursing Officer (CNO) #7 stated hall beds had been used at the facility's ED for at least 10 years. S/he stated the use of hall beds occurred on a weekly basis and was not tracked. CNO #7 stated the availability of using rooms in Zone 7 depended on staffing because Zone 7 was out of the way. CNO #7 stated staff schedule planning was based on history of ED patient census. S/he stated capacity was a big issue and s/he knew that hall beds were not used if other rooms were available. This was in contrast to observations and document review.

h) On 01/05/17 at 9:17 a.m. an interview was conducted with the Chief Operating Officer (COO #9). COO #9 stated s/he knew of the use of hall beds and did not believe there was a policy on the use of hall beds in the ED. COO #9 stated the use of hall beds was due to a capacity issue, the facility's ED was built for 50% of what the facility's ED was treating.

i) On 01/03/17 at 2:38 p.m. a review of the North ED staff meeting minutes was conducted. The staff minutes, dated 01/27/16, revealed immediate bedding as an agenda item discussed. The question "What are the barriers to bringing patients straight back to the ED?" was asked. One RN responded that a patient seemed irritated by being seen in a hall bed and a RN responded positively to the patient that they cared about the patient and wanted to get the patient in to see a provider as soon as the RN could. The importance of scripting when moving a patient into a hall bed was discussed so that the move was viewed as positive by the patient.