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The hospital failed to ensure patients who are triaged to the Zone II Emergency Department (ED) are afforded personal privacy during examination (See Tag A 143); The hospital failed to ensure patients in the Cardiac Cath Holding Area and Zone II ED receive care in a safe setting. The placement of ED Hold patients into the Cardiac Cath Holding Area with Cardiac procedure patients increases the risk of transmission of infections and/or adverse outcome to the Cardiac procedure patients. The use of a combined waiting room for both Cardiac Cath and ED patients increases risk of infection transmission. Placement of chairs and patients/visitors in the hallway outside the Cardiac Cath Holding Area and Zone II ED blocks egress of patients, staff and visitors. These failed practices result in unsafe care for all patients in these areas (See Tag A 144).

Based on observation, staff interview and medical record review it was determined the hospital failed to ensure patients who are triaged to the Zone II Emergency Department (ED) are afforded personal privacy during examination. This failure creates the potential for the rights of all patients who are sent to the Zone II ED to be violated.

Findings include:

1. Observation was conducted in the Zone II ED area from approximately 1:20 p.m. to 2:00 p.m. on 1/5/15. As the surveyors approached the entrance of the Zone II ED at 1:20 p. m. two (2) chairs, one of these a recliner, were observed in the hallway between the open doors of the Cardiac Cath Lab (on left) and Zone II ED (on right).

Physician's Assistant (PA) #1 was observed to be examining patient #6, who stood in front of the recliner. PA #1 was heard to be discussing treatment options with the patient.

The surveyors entered the Zone II ED and spoke with ED Nurse #1, at approximately 1:22 p.m., who confirmed the patient observed was an ED patient. Review of the ED record revealed the patient presented to the ED with a chief complaint of cough.

PA #1 was interviewed, at approximately 1:25 p.m., regarding the examination of patient #6 in the hallway. She acknowledged this occurred and agreed patients cannot be afforded privacy in the hallway.

The surveyors' observation of patient #6 being examined in the hallway outside the ED was discussed with the Chief Nursing Officer at 2:20 p.m. on 1/5/15. She stated this practice was a mistake in judgement by ED staff.

Based on observation, staff interview and medical record review it was determined the hospital failed to ensure patients in the Cardiac Cath Holding Area and Zone II Emergency Department (ED) receive care in a safe setting. The placement of ED Hold patients into the Cardiac Cath Holding Area with Cardiac procedure patients increases the risk of transmission of infections and/or adverse outcome to the Cardiac procedure patients. The use of a combined waiting room for both Cardiac Cath and ED patients increases the risk of infection transmission. Placement of chairs and patients/visitors in the hallway outside the Cardiac Cath Holding Area and Zone II ED blocks egress of patients, staff and visitors. These failed practices result in unsafe care for all patients in these areas.

Findings include:

1. Observation was conducted in the Zone II ED and Cardiac Cath Holding Area from approximately 1:20 p.m. to 2:05 p.m. on 1/5/15. As the surveyors approached the entrance of the Zone II ED at 1:20 p. m. two (2) chairs, one of these a recliner, were observed in the hallway between the open doors of the Cardiac Cath Holding Area (on left) and Zone II ED (on right).

Physician's Assistant (PA) #1 was observed to be examining patient #6, who stood in front of the recliner. Another individual was sitting on the second chair. PA #1 was heard to be discussing treatment options with the patient. The patient was noted to be coughing. The patient was observed to be standing approximately eight (8) feet from the open doorway of the Cardiac Cath Holding Area. The patient's recliner and the chair beside it were observed to be partially blocking the doorway of the Zone II ED.

The surveyor entered the Zone II ED and spoke with ED Nurse #1, at approximately 1:22 p. m., who confirmed the patient observed was an ED patient. She stated the second individual in the other chair was with patient #6. Review of the ED record for patient #6 revealed the patient presented to the ED with a chief complaint of cough. ED Nurse #1 stated she would ensure the patient was provided a mask and that the doors to the Cardiac Cath Holding Area were closed. She also stated the Zone II ED had been so "backed up" recently with ED Hold patients, who were waiting for admission beds, that these patients were placed in the Cath Lab Holding Area for care.

PA #1 was interviewed at approximately 1:25 p.m. regarding the examination of patient #6 in the hallway. She acknowledged the patient "obviously" should not have been placed or examined in the hallway.

At approximately 2:15 p.m. on 1/5/15, the Risk Manager agreed placement of chairs and patients in the hallway blocked egress to the department.

2. The surveyors also observed, during this same timeframe, the Cardiac Cath Area and Zone II ED were sharing a waiting room. Signage indicated this space was for both populations and four (4) ED patients and Cardiac Cath family members were observed waiting in the shared room.

Interview with the Cardiovascular Services Manager was conducted at 1:55 p.m. on 1/5/15. She confirmed that ED Hold patients had been placed in the Cardiac Cath Holding Area on at least two (2) dates. She stated this was done when the Cath Lab census was low. The Manager stated the Cardiac Cath Holding Area used beds one (1) and two (2) for Cardiac procedure patients and beds three (3) through seven (7) were available for use by ED Hold patients. The Director stated the Cardiac procedure patients were cared for by the Cardiac Cath staff and the ED Hold patients were care for by nursing inpatient or float staff. When asked if the hospital had a procedure for ED overflow into the Cardiac Cath area she stated she did not know but confirmed the Cardiac Cath Unit had no such policy. When asked the diagnoses of patients who were commingled with the Cardiac Cath patients, the Director did not know.

The observation of the shared waiting room was discussed with the Director who stated every effort was made to schedule the Cardiac procedure patients so that they can come directly to the Holding Area and bypass the Waiting room. She did acknowledge there was no other waiting area available to the Cardiac procedure patients and it was possible for Cardiac procedure patients to share the waiting room with ED patients.

A request was made for any current policies or procedures for handling patient placement or overflow in high census periods.

3. Observation of the Cardiac Cath Holding Area was conducted at approximately 2:00 p.m. on 1/5/15. The Area was observed to contain seven (7) beds in a straight row along one wall. The cubicles were separated by walls and the opening into each cubicle was covered with a curtain.

Interview was conducted with the Chief Nursing Officer (CNO) at 2:20 p.m. on 1/5/15. She provided the policy "Patient Flow," last revised 4/14 and acknowledged she was not familiar with this nursing policy. She stated she thought the use of the Cardiac Cath Holding Area for ED Hold patients had occurred on at least two (2) dates but could provide no more information or documentation related to how this decision was made, dates this occurred or which patients and/or diagnoses of patients which were placed in the Cardiac Cath Unit. This information was requested. The CNO stated she saw no problem with the practice as Cardiac staff cared for Cardiac patients and nursing staff cared for ED Hold patients.

On 1/6/15 at 12 noon the hospital confirmed ED Hold patients were placed in the Cardiac Cath Unit on three (3) dates, 12/20/14, 12/31/14 and 1/2/15. The Risk Manager stated, at this time, the hospital has one hundred and sixty-three (163) available beds. Review of the census for the hospital revealed the census was one-hundred fifty-three (153) on 12/30/14, one-hundred forty-seven (147) on 12/31/14 and one-hundred fifty (150) on 1/2/15.

4. Phone interview was conducted with the ED Medical Director on 1/6/15 at 11:00 am. He stated he had never seen the census as high as it was recently. He also stated that during his twenty-six (26) years with the hospital, patients had never been diverted. The Medical Director explained that patients often want to stay in this hospital and the hospital doesn't divert. He acknowledged the hospital had no documentation of how the decision was made to co-mingle the patients in the Cardiac Cath Holding Area. The risk of cross contamination was discussed with the Medical Director and he acknowledged there was a risk. The Medical Director agreed the hospital needed a better process for determining how the ED overflow could be handled in a safe fashion.

5. The policy "Patient Flow, " was reviewed The policy states under Responsibility: " 1. It is the responsibility of Central Bed Management or the Administrative Supervisor to coordinate patient placement within the organization. 2. It is the responsibility of the Director of Emergency Department or their designee to communicate the need for patient bed placement to Central Bed Management or the Administrative Supervisor. 3. It is the responsibility of the Central Bed Management or the Administrator on call to implement the plan for patient intervention. 4. It is the Central Bed Management or the Administrative Supervisor's responsibility to contact local hospitals to establish if there is bed availability. 5. It is the responsibility of Administration to place a critical bed notice in the Medical Staff Lounge. " The policy states in part under Procedure: "Patients may be boarded in Same Day Surgery, Cath Lab holding, and the Post Anesthesia Care Unit."

Interview was conducted with the Director of Central Bed Management at 1:35 p.m. on 1/6/15. The CNO also sat in on most of this interview. The Director stated she had been at the hospital for nine (9) years and this is the first time the hospital has had to implement the Patient Flow policy.

The Hospital census for this time period was reviewed with the Director. She stated the hospital was full (at capacity or beyond) on 12/30/14 and 12/31/14 and 1/2/15, 1/4/15, 1/5/15 and 1/6/15.

The Director confirmed the hospital did implement the policy on 12/30/14, 12/31/14 and 1/2/15. When the policy was reviewed with her, she acknowledged the hospital failed to follow policy and contact local hospitals to establish if there was bed availability on any of the above dates. The Patient Flow policy was reviewed with the Director and both she and the CNO acknowledged the recent management of patient flow into the Cardiac Cath Holding area did not completely follow policy and the current policy would need to be revised and reviewed with staff.

The Director also stated she was not aware there were cardiac patients in the Cardiac Cath Holding Area during the periods the ED Hold patients were placed in the Cardiac area. She acknowledged the practice of commingling patients in the Cardiac Cath Holding Area could pose an infection risk to the Cardiac Cath patients. She stated the diagnosis of ED Hold patients placed in the Cardiac Area should be considered prior to placement The Director acknowledged she had not been part of any such consideration.

The Director was questioned about the appropriateness of using the Same Day Surgery, Cardiac Cath Holding Area and Post Anesthesia Care Unit for patient overflow as the policy states. She stated she believed it was meant that these areas were to be considered for placement of overflow patients when empty, but acknowledged the policy did not state this. The Director acknowledged there was a breakdown in communications/oversight with Bed Management as she was not aware the Cardiac procedures were occurring while the ED Hold patients were placed there.

Interview was conducted with the Infection Control Nurse at 3:30 p.m. on 1/6/15. She acknowledged at this time that she was unaware the ED Hold Patients were commingled with Cardiac Cath patients. She agreed this could pose an infection risk to Cardiac procedure patients.

6. Review of both the cardiac procedure patients and ED Hold patients for 12/30/14, 12/31/14 and 1/2/15 revealed three (3) ED Hold patients were placed in the Cardiac Cath Holding Area with Cardiac Procedure patients on 12/30/14 and 12/31/14.

On 12/31/14 patient #8, an ED Hold patient, with diagnosis of Pneumonia, was placed in Cardiac Cath Holding while patient #11 was in this area for a Cardiac procedure.

On 12/31/14 patient #7, an ED Hold patient, with diagnosis of ETOH (Alcohol) Intoxication, Suicidal Ideation and Homicidal Ideation, was placed in Cardiac Cath Holding Area. Review of the record revealed the patient was noted to be agitated and cursing at intervals and required a sitter to stay with him while being cared for in the Cardiac Cath area. The record reflected this patient was held for a mental hygiene hearing and became an involuntary admission to the State Psychiatric Hospital. Patient #11, who was in for a cardiac procedure, was in the Cardiac Cath Area with patient #7.

The potential risk this patient could pose to a Cardiac Cath patient was discussed with the CNO at 1:45 p.m. on 1/6/15. She stated she could not do anything to control the behavior of patient #7. She also stated she made rounds in the Cardiac Cath Holding Area on 12/31/14 and noted no problems.

On 12/30/14 patient #9, an ED Hold patient with Chest Pain and elevated cardiac enzymes, was placed in the Cardiac Cath Holding Area. Patient #9 had a low grade fever. Patient #12 who was in for a Cardiac procedure was in the Area at the same time.

7. At 12:15 p.m. on 1/7/15 the Chief Executive Officer (CEO) confirmed the hospital never contacted other hospitals regarding bed availability. He stated no other hospitals are contacted because Weirton Medical Center (WMC) already knows all other hospitals in the area are full. He also stated all other hospitals are dealing with patient overflow in the same manner as WMC. The CEO stated there is no regulation that prevents placing ED Hold patients in the Cardiac Cath Hold Area.