The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CENTURA HEALTH-LITTLETON ADVENTIST HOSPITAL 7700 S BROADWAY LITTLETON, CO 80122 Feb. 17, 2015
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on the manner of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.41, PHYSICAL ENVIRONMENT, was out of compliance.

A0725 - Standard: Physical Environment: The extent and complexity of facilities must be determined by the services offered. The facility failed to ensure the Emergency Department (ED) egress hallways allowed for safe egress from the Department by allowing hall beds, equipment, and patient visitors to obstruct the emergency suite corridors and egress corridors. Furthermore, the facility failed to ensure the safety of hall bed patients by neglecting to provide a call mechanism at every hall bed. The failure created the potential for an increased risk to patient safety related to the congestion of the emergency suite corridors. Additionally, the lack of a call mechanism created the potential for negative patient outcomes.
VIOLATION: COMPLEXITY OF FACILITIES Tag No: A0725
Based on observations, interviews, and document review the facility failed to ensure the Emergency Department (ED) egress hallways allowed for safe egress from the Department by allowing hallbeds, equipment, and patient visitors to obstruct the emergency suite corridors and egress corridors. Furthermore, the facility failed to ensure the safety of hallbed patients by neglecting to provide a call mechanism at every hallbed.

The failure created the potential for an increased risk to patient safety related to the congestion of the emergency suite corridors. Additionally, the lack of a call mechanism created the potential for negative patient outcomes.

FINDINGS:

Policy

According to the facility policy, "Hospital Plan of Care," patients can expect to receive the following: Standard VI- Patients can expect nursing care to be provided within a safe environment.

The facility policy, "Patient Rights," stated the facility shall provide care to patients within a framework that recognizes and supports the rights of each patient. In addition, the facility's Patient Bill of Rights stated that patients have the right to receive care in a safe setting.

1. The patient hallbeds and equipment stored throughout the ED hallways posed a safety risk to patient care and patient egress from the ED.

a) On 02/10/15 at 2:30 p.m., a tour of the ED was conducted with the Regulatory Readiness Coordinator (RRC) and the ED Nurse Manager (NM). The ED Nurse Manager stated the unit was divided into a trauma side and a medical side. In total, the ED had 28 beds. Five dedicated trauma rooms, 7 dedicated hallbeds, 3 psychiatric-safe rooms, 2 triage beds, and 11 dedicated medical rooms. Hallbeds A, C, D, and E were located on the medical side of the ED. Hallbeds X, Y, and Z were located on the trauma side of the ED.
Upon entry to the ED, initial observation revealed Patient #17 and Patient #23 placed in hallbeds. The NM stated when the ED was full, hallbeds would be used for overflow patients. Patients who were admitted to a hallbed could be treated and discharged from a hallbed, located in an open corridor in the ED.

Further investigation of the first hallbed revealed a label on the wall which stated hallbed D. Hallbed D was located between rooms 15 and 16. Patient #17 was in street clothes lying in hallbed D with a visitor sitting in a chair at the head of the bed. An Intravenous (IV) pole and a vital signs (VS) machine were positioned at the head of the bed. A code cart was positioned across from hallbed D, which further congested the space in the hallway. Directly in line, on the same side of the hall, was Patient #23 in hallbed C. Hallbed C was located between rooms 16 and 17.

Upon further observation of the ED an ultrasound machine, blood pressure machine, 2 core carts, and 2 mobile trauma carts were located between Trauma Rooms 1 and 2. Hallbed Z was located directly across the hall from Trauma Rooms 1 and 2. The equipment and hallbed Z resulted in congestion of the trauma hallway. The congested area of the trauma hallway was at the end of the hall nearest the double doors where patients arriving by ambulance would enter the ED by stretcher or gurney. Patients being admitted to Trauma Room 1 would need to be taken through the congested area described here. The ambulance arrival area served as an egress to the outside of the building.

b) On 2/11/15 at 4:05 p.m. a tour of the ED was conducted with the NM, the ED Director and the RRC. The trauma hallway was obstructed by hallbed Y, hallbed Z, and equipment required to provide care to patients. Consistent with previous tours of the facility's ED, the observed equipment across from hallbed Z, between Trauma Rooms 1 and 2, next to a built in column was: a VS machine, SonoSite Ultrasound Machine #5 on a cart with wheels, adult code cart, and 2 mobile trauma carts. This equipment further congested the trauma hallway and the space for adequately treating a patient admitted to a hallbed. A hallway width of approximately 4 feet was measured from the edge of hallbed Z to the column and the stored equipment. The trauma hallway served as an egress corridor for patients, visitors, and staff. The same equipment described here was present in the trauma hallway upon observations conducted of the ED on 02/10/15 at 2:30 p.m.

c) On 02/11/15 at 1:34 p.m., an interview was conducted with RN #5. RN #5 stated hallbeds were used for less acute patients, and s/he stated that visitors were allowed to sit with patients in the hallways. RN #5 stated all hallbeds should have a chair at the foot of the bed for visitors. RN #5 stated that s/he tried to keep the chair at the end of the bed and out of the hallway space, so the visitors would not further obstruct the hallway space. However, s/he stated this was not consistent practice throughout ED hallways.

Additionally, RN #5 stated that a patient could be suctioned in the hallway. The suction equipment was located on the code cart. Depending on preference, an ED staff member could take the entire code cart to the hallbed or remove just the suction portion to assist the patient.

d) On 02/11/15 at 4:05 p.m., an interview was conducted with the NM. The NM stated if a patient in a hallbed needed to be suctioned the staff member could use the suction on the code cart or remove the suction from the code cart to assist the patient. S/he stated it depended on the preference of the staff member. There was not a process in place to ensure the code cart would not further obstruct the hallway space while the staff member suctioned a patient.

2. The facility failed to provide a call mechanism for all hallbeds in the ED for patient use and safety.

a) On 02/11/15 at 4:05 p.m., a walk-through of the ED with the RRC, the NM, and the ED Director was conducted. During initial interview with the NM, s/he stated every hallbed had a call mechanism. Observations of the ED revealed call mechanisms were not present at 4 of the 7 hallbeds (Hallbeds A, X, Y, and Z). Call mechanisms were present at Hallbeds C, D, and E. Call mechanisms were also present in ED patient rooms and in all the restrooms used by patients in the ED.

Upon further discussion, the NM stated the trauma side hallbeds (X, Y, and Z) did not have call mechanisms. S/he stated this was because those beds were close to the nurse's station, were able to be seen, and the Unit Coordinators (UC) were able to hear if a patient called out for help. However, during observation of the ED Hallbeds A, Y, and Z were not visible from the 2 nurse's stations in the ED. The NM stated that a situation where a patient in a hallbed without a call mechanism was unable to call out for assistance had not yet happened in the facility's ED but could happen.

b) On 02/11/15 at 4:21 p.m., an interview was conducted with UC #6 who worked on the medical side of the ED. UC #6 stated it was not his/her responsibility to monitor the patient's condition in the hallbeds, however, s/he would do his/her best to observe those patients. UC #6 explained that it was his/her responsibility to observe the central monitor located at his/her desk. The central monitor was in place to indicate when a call mechanism was activated by a patient who needed assistance. Further, UC #6 stated that every bed in the ED, including hallbeds, had a call mechanism in place. UC #6 was asked if s/he could see hallbed A from his/her position at the desk and UN #6 confined that s/he could not see this hallbed. (Hallbed A did not have a call mechanism.)

c) On 02/11/15 at 4:40 p.m., an interview was conducted with UC #7 on the trauma side of the ED. S/he stated Hallbeds X, Y, and Z did not have a call mechanism. The UC stated there were always staff members available to assist hallbed patients when they asked for help. S/he stated, "Patients can say, 'hey, I need to use the bathroom,' and someone will take them to the bathroom." UC #7 stated s/he was unable to visualize hallbed Y and could only see the foot of hallbed Z from his/her workstation. UC #7 explained s/he tried to walk around and observe the hallbed patients, but s/he was not able to leave the desk unless there was another person in his/her place to answerer phones and to monitor patients with call mechanisms in place.

d) On 02/12/15 at 9:18 a.m., an interview was conducted with UC #10 who was monitoring the patient call system on the trauma side of the ED. UC #10 stated s/he was not required to monitor patients in hallbeds and further stated, "I don't do patient care." UC #10 confirmed that s/he could not see hallbeds Z and Y from his/her position at the desk.

e) A list of ED patients, and the beds patient were admitted to, was requested for 12/07/14, from 12:00 p.m. through 3:00 a.m., and for 01/12/15 and 02/10/15, 12:00 midnight for a 24 hour period. For these time frames, 34 patients were listed as being admitted to a hallbed. The ED NM stated the lists were generated manually by multiple staff members, upon surveyor's request, and took hours to produce as the facility had no mechanism in place to identify patients who received care in hallbeds.

From the bed list, generate by the facility, separate from patient medial records, 22 of the 34 patients were admitted to hallbeds without a call mechanism in place. These were hallbeds A, X, Z, and Y. The list generated by the facility also showed 15 of the 22 patients admitted to hallbeds without a call mechanism in place remained in hallbeds throughout the ED visit and were not moved into ED rooms.

Of the 15 patients admitted to hallbeds with no call mechanism in place, who remained in hallbeds throughout the entire ED visit, 7 of these medical records revealed a Registered Nurse documented in the patient's medical record, "Keep Call Light Within Reach - Y" indicating a call mechanism was in place and available to the patient to use in order to call for help or assistance from staff. (Patients #12, #27, #30, #37, #39, #43, and #44.)
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the manner of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance.

A0143 - 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 egress corridors. This failure created instances in which patients received physical assessments, nursing care, and diagnostics while in open corridors within the Emergency Department (ED) without processes in place to ensure their personal privacy.

A0144 - 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 patients in the Emergency Department (ED) by allowing hall beds, equipment, and patient visitors to obstruct the emergency suite corridors and egress corridors. Furthermore, the facility failed to ensure the safety of hall bed patients by neglecting to provide a call mechanism at every hall bed. This failure created the potential for an increased risk to patient safety related to the congestion of the emergency suite corridors. Additionally, the lack of a call mechanism created the potential for negative patient outcomes.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observations, interviews, and document review, the facility failed to have a process in place to ensure the personal privacy of patients who received care while placed in hallbeds located in the emergency department's egress corridors.

This failure created instances in which patients received physical assessments, nursing care, and diagnostics while in open corridors within the Emergency Department (ED) without processes in place to ensure their personal privacy.

FINDINGS:

POLICY

According to the policy, Hospital Plan of Care, patients can expect to have their need for privacy respected and information about them kept confidential.

According to the Patient Bill of Rights, personal privacy, comfort and security will be provided to patients to the extent possible during their stay in the facility.

According to the Emergency Department protocol, Care of the ED Patients, the ED will provide privacy for the psychosocial assessment.

1. The Emergency Department (ED) staff provided care to patients in hallbeds, located in egress corridors within the department, without ensuring the use of screens, curtains, or other measures to ensure patients' personal privacy and the confidentiality of sensitive patient-staff conversations.

a) On 02/10/15 at 2:30 p.m., a tour of the ED was conducted with the Regulatory Readiness Coordinator (RRC) and the ED Nurse Manager (NM). The NM stated the unit was divided into a trauma side and a medical side. In total, the ED had 28 beds which included 5 dedicated trauma rooms, 11 dedicated medical rooms, 3 psychiatric-safe rooms, 2 triage beds, and 7 dedicated hallbeds. Hallbeds A, C, D, and E were located on the medical side of the ED. Hallbeds X, Y, and Z were located on the trauma side of the ED. The hallbeds were located in open corridors within the ED. Hallbed patients, patients admitted to ED rooms, and visitors to the ED had access to and were moved through the ED corridors. Patients admitted to hallbeds were visible to other patients and visitors to the ED.

Upon entry to the ED, observation revealed Patient #17 and Patient #23 placed in hallbeds. The NM stated when the ED patient rooms were full, hallbeds were used for overflow patients. The NM stated patients who were admitted to a hallbed could be treated and discharged from the hallbed without being in a private ED room.

Patient #17 was observed in hallbed D, on the medical side of the ED, in street clothes lying on the bed with a visitor sitting in the hallway, at the head of the bed. Hallbed D was located between rooms 15 and 16. Directly in line, on the same side of the hall, Patient #23 was observed in hallbed C. Hallbed C was located between rooms 16 and 17. No privacy screen or curtain was present for either patient. The patients were receiving care in open corridors in which other patients and visitors to the ED also had access.

b) On 02/11/15 at 9:14 a.m., the ED was observed with the NM who stated to ensure privacy for patients admitted to hallbeds, facility staff would use portable screens positioned around the beds. The NM stated there were 7 hallbeds in the ED. The NM could not state definitively how many screens were available in the ED for this purpose, but believed there were 2. The NM stated screens would be used to better ensure patient privacy when patients received physical exams, EKGs, or "procedures" but it would depend on what the nurse or physician was doing and it was up to staff to obtain the screen. The NM stated patients could receive suctioning while in hallbeds, as an example of a treatment.

The NM stated, to keep conversations confidential between patients in hallbeds and their providers, staff would keep their voices low.

The NM stated s/he did not know how the expectation for personal privacy of patients who received care in hallbeds was "relayed" to nurses and physicians and could not state how frequently this topic was discussed with staff, or if it was discussed with staff. The NM stated s/he did not discuss this topic with nursing staff as all nurses received basic education regarding patient rights upon hire and annually and patients' personal privacy was part of this education.

c) On 02/11/15 at 9:43 a.m., further observation of the ED was conducted with the NM to locate privacy screens. One privacy screen was found in a storage area at the end of the trauma hallway. The NM then confirmed the ED had 1 privacy screen to use for 7 hallbeds and stated there were times when all 7 beds are being used for patients admitted to the ED.

d) On 02/11/15 at 9:45 a.m., an interview was conducted with Registered Nurse (RN) #9 who stated s/he functioned as a Charge Nurse and typically would not use a privacy screen for patients in hallbeds. RN #9 stated if s/he was conducting a more sensitive procedure for patients s/he would "flip" the hallbed patient with a patient in an ED room, meaning s/he would place a room patient in the hallbed and then place the hallbed patient in a room for more privacy. RN #9 stated patients did receive initial physician physical examinations and nursing assessments in hallbeds and this would not necessarily involve the use of a privacy screen.

e) On 02/11/15 at 1:34 p.m., an interview was conducted with RN #5 who stated the ED had 1 or 2 privacy screens and these would be used to better ensure patient privacy during physical examinations. RN #5 stated patients who received care in hallbeds were simple cases such as a finger laceration. RN #5 stated instead of using a privacy screen, s/he sometimes repositioned hallbeds to allow for more patient privacy. RN #5 stated patients were "flipped" from hallbeds to ED rooms "daily" which still meant a patient was in a hallbed. RN #5 stated it was at times uncomfortable speaking with patients in hallbeds because of the need for privacy of conversations and when gathering sensitive patient information. RN #5 stated patient privacy was part of nurses' annual competencies, but was general and did not offer guidance on the issue of hallbeds in the ED and the use of privacy screens. RN #5 stated the appropriate use of privacy screens for hallbed patients was not discussed by nursing staff or by nurse managers.

f) On 02/11/15 at 3:53 p.m., the ED NM was interviewed and stated the bed location, including hallbeds, or room patients admitted to the ED was reflected in the patient's medical record. The NM stated s/he could run an audit showing the use of hallbeds in the ED.

g) On 02/12/15 at 9:35 a.m., an audit of hallbed use from 12/01/14 to 02/12/15, was requested of the ED NM who stated s/he would have to run this audit by each individual patient admitted to the ED. The NM clarified her statement from 02/11/15 and stated s/he did not run an audit as described but could run an audit on any individual patient seen in the ED to look for a number of activities, one being the movement of a patient from the time of admission to the ED until the time a patient was discharged , transferred, or admitted to the inpatient unit of the facility. The NM stated s/he did not run an audit of hallbed usage as previously described and so did not have easily accessed information showing which patients were admitted to hallbeds, and what care was provided to patients while they were in hallbeds.

The NM stated December, 2014, and January, 2015 were two heavy volume months for ED visits (December, 2014 = 3072 ED visits and January, 2015 = 2966 ED visits). The NM stated December, 2014 was the busiest month in the ED to date and hallbeds were routinely used.

h) On 02/12/15 at 9:35 a.m., the Director of Emergency and Critical Care Services was interviewed and stated utilization of hallbeds was not looked at individually as "its own issue" as these beds were counted as regular ED beds. The Director stated hallbeds were not tracked for usage or for the type of care provided to patients in these beds. The Director further stated because the type of care provided to these patients was not reviewed by the facility as separate from the beds in ED rooms, the issue of ensuring patients' personal privacy when being seen in hallbeds was not reviewed by the facility. The Director stated there was no process in place to let the facility know if or when the privacy screen was being used and exactly what care was being provided in hallways.

The Director stated education of ED staff regarding patients' personal privacy was general and was provided to staff annually with no specific education or requirements regarding ensuring personal privacy to patients receiving care in hallbeds including when the privacy screen should be used.

The Director stated patients receiving care in hallbeds did receive physical assessments and could receive suctioning, for example, while in a hallbed. The Director stated patients were "flipped" from a hallbed to a room, meaning the patient previously in an ED room could be moved to a hallbed. When patients were moved from a room bed to a hallbed, they could still be in a gown.

i) On 02/12/15 at 3:56 p.m., the Emergency Department Medical Director was interviewed and stated there was no specific training of medical staff regarding patients' personal privacy while receiving care in hallbeds but staff did know to keep their voices lowered. The Director stated patients requiring "sensitive examinations" were moved to rooms in the ED, and gave the example of pelvic exams as being this type of examination. The Director stated patients may be in gowns when receiving care in the hallbeds.

j) A list of ED patients, and the beds patient were admitted to, was requested for 12/07/14, from 12:00 p.m. through 3:00 a.m., and for 01/12/15 and 02/10/15, 12:00 midnight for a 24 hour period. For these time frames, 34 patients were listed as being admitted to a hallbed. The ED NM stated the lists were generated manually by multiple staff members and took hours to produce as the facility had no mechanism in place to identify patients who received care in hallbeds.

ED medical records were reviewed for each of the 34 patients who received care while in hallbeds (Patients #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46). The medical records contained no documentation stating which beds patients were admitted to. The list stated that in 12 of the 34 patient visits, at some point during the patient's ED visit, the patient was moved from a hallbed to a bed in an ED room. The medical records for these patients, however, did not state if or when the patients were moved to a room bed so it was not possible to know what care was provided while patients were in a hallbed and what care was provided in a room bed. The list generated did not show when patients were "flipped" (when a patient who had been in a room bed was moved to a hallway bed). Staff members throughout the survey stated that "flipping" of patient beds occurred daily in the ED.

Each of the patients admitted to a hallbed received some type of physical examination by a physician or a mid-level provider under the direction of a physician. Patients also received an initial nursing assessment, and some received subsequent nursing assessments. The physical examinations and the initial nursing assessments were documented as being performed after patients were triaged, in a triage room, and soon after being admitted to a hallbed. Because the medical records did not indicate where care was provided, including the physicians' physical examination and the nurses' initial assessment, and because facility staff did not track or have knowledge of the locations where care was provided, it was possible that physical examinations and initial nursing assessments were performed in hallbeds. The medical records did not reflect if a privacy screen was used when physical examinations and nursing assessment were performed. The facility did not have a process in place to know if or when a privacy screen was used for patients who received care while in hallbeds, including physical examinations and nursing assessments.

k) The following medical record review summarys show examples of some of the care provided to patients in hallbeds:

Patient #12: arrived by ambulance and was admitted to hallbed Y, which from observations, had no call light mechanism available. The patient was documented as a "high" fall risk. The patient was 22 weeks pregnant. The record revealed the patient received x-rays of wrists and the right knee and a bedside ultrasound for fetal movement. The record revealed a nurse dressed the patient's abrasions. The ED physician documented "no murmurs, rubs or gallops" for the patient's cardiac status and, "abdomen soft and non-tender. Palpable fundus just a little bit above halfway between her pubic bone and her umbilicus. It is firm," for the patient's abdominal examination. The initial Registered Nurse (RN) assessment revealed all expected assessment components including an OB/GYN assessment in which the patient stated she was pregnant, the number of previous pregnancies, and the number of live births she had experienced. The RN psychosocial assessment revealed the patient answered questions regarding neglect and abuse, feelings of helplessness or depressions, and if she was a danger to herself or others.

The time of the initial RN assessment to the time the patient was sent to the Obstetrics unit for fetal monitoring was 1 hour, 18 minutes. The bed utilization list provided by the facility, showed the patient was in a hallbed during the entire ED visit. There was no indication in the patient's medical record that a privacy screen was used at any time during the patient's visit.

Patient #13: was admitted to hallbed X, which from observations, had no call light available. The patient was documented as a "high" fall risk, received an X-ray, cast padding and splinting of his/her ankle, instructions for the use of crutches, and pain medication. The RN psychosocial assessment revealed the patient answered questions regarding neglect and abuse, feelings of helplessness or depressions, and if s/he was a danger to herself or others.
The time of the initial RN assessment to the time the patient was discharged from the ED was 4 hours, 7 minutes. The bed utilization list, provided by the facility, showed the patient was moved to a room bed at some point during his/her ED visit but the time of this move was not documented on the list or in the patient's medical record. There was no indication in the patient's medical record that a privacy screen was used at any time during the patient's visit while in the hallbed.

Patient #16: was admitted to hallbed C. The physician's physical examination stated, "there are no retractions, lungs are clear to auscultation," and, "Abdomen is soft, mild suprapubic tenderness to palpation no masses, bowels sounds normal. Bilateral minimal CVA tenderness." (Costovertebral angle tenderness is a physical assessment in which pain is elicited by percussion of the area of the back overlying the kidney.) The physician's documentation further read that the patient denied pregnancy, was sexually active, and went on to describe the types of sexual activity the patient participated in. The RN psychosocial assessment revealed the patient answered questions regarding neglect and abuse, feelings of helplessness or depressions, and if she was a danger to herself or others. The time of the initial RN assessment to the time the patient was discharged from the ED was 1 hours, 5 minutes. The bed utilization list, provided by the facility, showed the patient was in a hallbed during the entire ED visit. There was no indication in the patient's medical record that a privacy screen was used at any time during the patient's visit while in the hallbed.

Patient #36: arrived by ambulance and was admitted to hallbed X, which from observations, had no call light available. The initial RN assessment was performed at 9:26 a.m., 18 minutes after arrival, and stated the patient had a bruise on his/her right flank and a feeding tube in place for post-surgery swallowing issues. The time of the initial RN assessment to the time the patient was discharged from the ED was 3 hours, 7 minutes. The bed utilization list, provided by the facility, showed the patient was moved to a room bed at some point during his/her ED visit but the time of this move was not documented on the list or in the patient's medical record. There was no indication in the patient's medical record that a privacy screen was used at any time during the patient's visit while in the hallbed.

Patient #39: was admitted to hallbed X, which from observations, had no call light available. The physician's physical examination revealed, "abdomen soft, mild tenderness in LL quadrant and suprapubic. No rebound or guarding." The RN psychosocial assessment revealed the patient answered questions regarding neglect and abuse, feelings of helplessness or depressions, and if s/he was a danger to herself or others. The patient received intravenous (IV) line placement and medications administered by IV 6 times during the ED visit. The time of the initial RN assessment to the time the patient was discharged from the ED was 4 hours, 23 minutes. The bed utilization list, provided by the facility, showed the patient remained in the hallbed during the entire ED visit. There was no indication in the patient's medical record that a privacy screen was used at any time during the patient's visit while in the hallbed.

Patient #40: was admitted to hallbed X, which from observations, had no call light available. The RN assessment revealed the patient stated s/he was anxious about the IV start, stressed because his/her spouse had just had surgery and was hospitalized , and the patient began to hyperventilate. The physician's notes stated, "results of the patient's imaging and laboratory testing were discussed with the patient in depth and the patient was discharged with return precautions." The time of the initial RN assessment to the time the patient was discharged from the ED was 2 hours, 13 minutes. The bed utilization list, provided by the facility, showed the patient remained in the hallbed during the entire ED visit. There was no indication in the patient's medical record that a privacy screen was used at any time during the patient's visit while in the hallbed.

Patient #42: was admitted to hallbed C and moved to hallbed A. From observations, hallbed A had no call light available. The patient was 5 months pregnant and while in the ED received a throat swab, venipuncture for a blood sample, and monitoring for fetal heart tones. The RN psychosocial assessment revealed the patient answered questions regarding neglect and abuse, feelings of helplessness or depressions, and if s/he was a danger to herself or others. The time of the initial RN assessment to the time the patient was discharged from the ED was 1 hours, 43 minutes. The bed utilization list, provided by the facility, showed the patient remained in a hallbed during the entire ED visit. There was no indication in the patient's medical record that a privacy screen was used at any time during the patient's visit while in the hallbed.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, interviews, and document review the facility failed to ensure the safety of patients in the Emergency Department (ED) by allowing hallbeds, equipment, and patient visitors to obstruct the emergency suite corridors and egress corridors. Furthermore, the facility failed to ensure the safety of hallbed patients by neglecting to provide a call mechanism at every hallbed.

The failure created the potential for an increased risk to patient safety related to the congestion of the emergency suite corridors. Additionally, the lack of a call mechanism created the potential for negative patient outcomes.

FINDINGS:

Policy

According to the facility policy, "Hospital Plan of Care," patients can expect to receive the following: Standard VI- Patients can expect nursing care to be provided within a safe environment.

The facility policy, "Patient Rights," stated the facility shall provide care to patients within a framework that recognizes and supports the rights of each patient. In addition, the facility's Patient Bill of Rights stated that patients have the right to receive care in a safe setting.

1. The patient hallbeds and equipment stored throughout the ED hallways posed a safety risk to patient care and patient egress from the ED.

a) On 02/10/15 at 2:30 p.m., a tour of the ED was conducted with the Regulatory Readiness Coordinator (RRC) and the ED Nurse Manager (NM). The ED Nurse Manager stated the unit was divided into a trauma side and a medical side. In total, the ED had 28 beds. Five dedicated trauma rooms, 7 dedicated hallbeds, 3 psychiatric-safe rooms, 2 triage beds, and 11 dedicated medical rooms. Hallbeds A, C, D, and E were located on the medical side of the ED. Hallbeds X, Y, and Z were located on the trauma side of the ED.
Upon entry to the ED, initial observation revealed Patient #17 and Patient #23 placed in hallbeds. The NM stated when the ED was full, hallbeds would be used for overflow patients. Patients who were admitted to a hallbed could be treated and discharged from a hallbed, located in an open corridor in the ED.

Further investigation of the first hallbed revealed a label on the wall which stated hallbed D. Hallbed D was located between rooms 15 and 16. Patient #17 was in street clothes lying in hallbed D with a visitor sitting in a chair at the head of the bed. An Intravenous (IV) pole and a vital signs (VS) machine were positioned at the head of the bed. A code cart was positioned across from hallbed D, which further congested the space in the hallway. Directly in line, on the same side of the hall, was Patient #23 in hallbed C. Hallbed C was located between rooms 16 and 17.

Upon further observation of the ED an ultrasound machine, blood pressure machine, 2 core carts, and 2 mobile trauma carts were located between Trauma Rooms 1 and 2. Hallbed Z was located directly across the hall from Trauma Rooms 1 and 2. The equipment and hallbed Z resulted in congestion of the trauma hallway. The congested area of the trauma hallway was at the end of the hall nearest the double doors where patients arriving by ambulance would enter the ED by stretcher or gurney. Patients being admitted to Trauma Room 1 would need to be taken through the congested area described here. The ambulance arrival area served as an egress to the outside of the building.

b) On 2/11/15 at 4:05 p.m. a tour of the ED was conducted with the NM, the ED Director and the RRC. The trauma hallway was obstructed by hallbed Y, hallbed Z, and equipment required to provide care to patients. Consistent with previous tours of the facility's ED, the observed equipment across from hallbed Z, between Trauma Rooms 1 and 2, next to a built in column was: a VS machine, SonoSite Ultrasound Machine #5 on a cart with wheels, adult code cart, and 2 mobile trauma carts. This equipment further congested the trauma hallway and the space for adequately treating a patient admitted to a hallbed. A hallway width of approximately 4 feet was measured from the edge of hallbed Z to the column and the stored equipment. The trauma hallway served as an egress corridor for patients, visitors, and staff. The same equipment described here was present in the trauma hallway upon observations conducted of the ED on 02/10/15 at 2:30 p.m.

c) On 02/11/15 at 1:34 p.m., an interview was conducted with RN #5. RN #5 stated hallbeds were used for less acute patients, and s/he stated that visitors were allowed to sit with patients in the hallways. RN #5 stated all hallbeds should have a chair at the foot of the bed for visitors. RN #5 stated that s/he tried to keep the chair at the end of the bed and out of the hallway space, so the visitors would not further obstruct the hallway space. However, s/he stated this was not consistent practice throughout ED hallways.

Additionally, RN #5 stated that a patient could be suctioned in the hallway. The suction equipment was located on the code cart. Depending on preference, an ED staff member could take the entire code cart to the hallbed or remove just the suction portion to assist the patient.

d) On 02/11/15 at 4:05 p.m., an interview was conducted with the NM. The NM stated if a patient in a hallbed needed to be suctioned the staff member could use the suction on the code cart or remove the suction from the code cart to assist the patient. S/he stated it depended on the preference of the staff member. There was not a process in place to ensure the code cart would not further obstruct the hallway space while the staff member suctioned a patient.

2. The facility failed to provide a call mechanism for all hallbeds in the ED for patient use and safety.

a) On 02/11/15 at 4:05 p.m., a walk-through of the ED with the RRC, the NM, and the ED Director was conducted. During initial interview with the NM, s/he stated every hallbed had a call mechanism. Observations of the ED revealed call mechanisms were not present at 4 of the 7 hallbeds (Hallbeds A, X, Y, and Z). Call mechanisms were present at Hallbeds C, D, and E. Call mechanisms were also present in ED patient rooms and in all the restrooms used by patients in the ED.

Upon further discussion, the NM stated the trauma side hallbeds (X, Y, and Z) did not have call mechanisms. S/he stated this was because those beds were close to the nurse's station, were able to be seen, and the Unit Coordinators (UC) were able to hear if a patient called out for help. However, during observation of the ED Hallbeds A, Y, and Z were not visible from the 2 nurse's stations in the ED. The NM stated that a situation where a patient in a hallbed without a call mechanism was unable to call out for assistance had not yet happened in the facility's ED but could happen.

b) On 02/11/15 at 4:21 p.m., an interview was conducted with UC #6 who worked on the medical side of the ED. UC #6 stated it was not his/her responsibility to monitor the patient's condition in the hallbeds, however, s/he would do his/her best to observe those patients. UC #6 explained that it was his/her responsibility to observe the central monitor located at his/her desk. The central monitor was in place to indicate when a call mechanism was activated by a patient who needed assistance. Further, UC #6 stated that every bed in the ED, including hallbeds, had a call mechanism in place. UC #6 was asked if s/he could see hallbed A from his/her position at the desk and UN #6 confined that s/he could not see this hallbed. (Hallbed A did not have a call mechanism.)

c) On 02/11/15 at 4:40 p.m., an interview was conducted with UC #7 on the trauma side of the ED. S/he stated Hallbeds X, Y, and Z did not have a call mechanism. The UC stated there were always staff members available to assist hallbed patients when they asked for help. S/he stated, "Patients can say, 'hey, I need to use the bathroom,' and someone will take them to the bathroom." UC #7 stated s/he was unable to visualize hallbed Y and could only see the foot of hallbed Z from his/her workstation. UC #7 explained s/he tried to walk around and observe the hallbed patients, but s/he was not able to leave the desk unless there was another person in his/her place to answerer phones and to monitor patients with call mechanisms in place.

d) On 02/12/15 at 9:18 a.m., an interview was conducted with UC #10 who was monitoring the patient call system on the trauma side of the ED. UC #10 stated s/he was not required to monitor patients in hallbeds and further stated, "I don't do patient care." UC #10 confirmed that s/he could not see hallbeds Z and Y from his/her position at the desk.

e) A list of ED patients, and the beds patient were admitted to, was requested for 12/07/14, from 12:00 p.m. through 3:00 a.m., and for 01/12/15 and 02/10/15, 12:00 midnight for a 24 hour period. For these time frames, 34 patients were listed as being admitted to a hallbed. The ED NM stated the lists were generated manually by multiple staff members, upon surveyor's request, and took hours to produce as the facility had no mechanism in place to identify patients who received care in hallbeds.

From the bed list, generate by the facility, separate from patient medial records, 22 of the 34 patients were admitted to hallbeds without a call mechanism in place. These were hallbeds A, X, Z, and Y. The list generated by the facility also showed 15 of the 22 patients admitted to hallbeds without a call mechanism in place remained in hallbeds throughout the ED visit and were not moved into ED rooms.

Of the 15 patients admitted to hallbeds with no call mechanism in place, who remained in hallbeds throughout the entire ED visit, 7 of these medical records revealed a Registered Nurse documented in the patient's medical record, "Keep Call Light Within Reach - Y" indicating a call mechanism was in place and available to the patient to use in order to call for help or assistance from staff. (Patients #12, #27, #30, #37, #39, #43, and #44.)