HospitalInspections.org

Based on observation and interview the facility failed to ensure 3 (Patients #2, #7 and #11) of 11 sampled patients received care in a safe setting, resulting in patients #2, #7 and #11 not having the ability to call for assistance and the potential for less than optimal outcomes.

During a tour of the emergency department on 11/15/2021 at 1115 an interview with Patient #2 took place in her room. Patient #2 reported she had arrived in the emergency room with her husband on 11/14/2021 at approximately 1600. Her husband left in the late evening, and she did not have a call light to call for assistance until a new nurse came on in the morning on 11/15/2021. Patient #2 stated the nurse in the morning brought 4 different call light cords in to her room before she could get one to work. Patient #2 stated she had to use the bathroom "really bad".

All Emergency Department (ED) rooms were checked during the tour for functioning call lights with Staff G (ED Manager) and Staff H (ED Director). It was observed there were non-functioning call lights in patient rooms 16, and 21. Room #18 did not have a call light in the wall. A call light was on the counter, but no adapter was present to allow the cord to fit into the wall. While the surveyor observed Room #18 a patient was placed in Room #18. Staff G (ED Manager) found an adapter and plugged the call light in after the patient was in the room.

Patient #11 (in room 21) reported he had to use the restroom and needed water, but his call light was not working.

Staff J (Nurse Aide sitter for Patient #7) reported staff had removed the call light from the room (#16) for another patient room. It was observed there was no call light in Patient room #16. Staff J stated the Nurses told her if she needed assistance she could go get someone. When queried who would be supervising Patient #7 if she (Staff J) left to go get assistance, Staff J stated she didn't know.

In an interview with Staff I (Emergency Room Registered Nurse) on 11/15/2021 at 1135, she stated upon taking over care of Patient #2 at the beginning of her shift on 11/15/2021 in the morning, she found her without a call light. Staff I said she had to try four different call light cords before she found one that worked.

Review of Patient #2's medical record revealed per her History and Physical dated 11/14/2021 she was a 65-year-old female admitted through the emergency department with a chief complaint of chest palpitations associated with nausea and vomiting. In the ED she was noted to be tachycardic (fast heart rate) with atrial fibrillation (irregular heart rhythm), and low potassium. She was given antiarrythmic medication (Cardizem) and placed on a blood thinning intravenous medication (heparin).

Review of Patient #7's medical record revealed per her face sheet, dated 11/8/2021, she was a 45-year-old female on hold in the ED for psychiatric facility placement.

Review of Patient #11's medical record revealed per her History and Physical dated 11/14/2021 she was a 55-year-old male admitted through the emergency department with a chief complaint of shortness of breath and a history of heart stents.

In an interview on 11/16/2021 at 1036 Staff H (Director of ED) stated it was her expectation as a part of patient orientation to the ED room, that staff hand the patient the call light, instruct them how to use it and ensure it is in working order. Staff H stated there were enough working call light cords for each bed in the emergency department to have a call light.