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.

Based on facility policy, observation, medical record review, and staff and patient interviews, the facility failed to protect patient privacy by performing treatment in a location failed to allow for privacy of health, treatment, or health information. The facility staff also failed to close doors and curtains in patient treatment areas to provide personal privacy.


Review of the facility policy, PRB-6100, "Patient Rights and Responsibilities," effective date 11/1988, last revised 12/2011, revealed that the facility respects, promotes and protects the basic human rights of each individual. Further review revealed that patients were entitled to confidentiality regarding their medical care.
Observation on 09/20/16 at 9:30 a.m. of the ED department revealed a desk with mobile blood pressure/temperature machine that was noted to be situated just inside the entrance to the ED waiting room. No walls or barriers were present around the desk area. There was a rope barrier which was being used for line formation at approximately five (5) feet in front the desk. Another patient and family member were noted to be waiting in line. Patient#1 was observed being triaged by the Registered Nurse RN#4 at the desk. RN#4 was overheard to be asking patient #1 about their reason for being in the ED. The conversation between the RN and the patient could be heard from the line, and people were noted to be watching and listening to the patient as he/she spoke with the RN. This surveyor was able to hear the conversation between the RN and the patient from the line area.
Observation on 09/20/16 at 9:44 a.m. of the ED department from the waiting area revealed patient #1 in one (1) of two (2) treatment rooms located behind the glass-walled registration desk. The door to the treatment room was open, and the patient was observed having his/her blood drawn. The patient was noted to be wincing in pain and crying as his/her blood was drawn. The patient was observed making eye contact with this surveyor who was observing from the waiting area near the ED entrance. Another patient in the ED waiting area was observed to be watching patient #1 receiving treatment in the treatment room.
Observation on 09/20/16 at 9:40 a.m. of the ED department revealed patient #2 being triaged at the triage desk in the ED waiting room. RN#4 was observed asking the patient what their medical problem was, and the patient was overheard stating his/her medical complaint. As the triage of the patient continued, a patient waiting at the roped barrier was noted to be watching and listening as patient#2 was assessed.
During an interview with the ED Director (EDD#3) on 09/20/16 at 4:25 p.m. in the Conference Room, the EDD stated that the secondary triage area at the desk in the ED waiting room was initiated with the idea that patients could be better visualized by nursing staff while waiting in the ED. The EDD further stated that secondary triage was also being used to allow patients to be more quickly assessed. The EDD explained that the triage area was closed down shortly after the surveyor's tour of the ED when it was discovered that patients' information could be easily overheard. The EDD acknowledged that the area being used in the waiting room for triage did not ensure the privacy of patients.
During an interview with RN (#4) on 09/21/16 at 8:14 a.m. in the Conference Room, the RN revealed that 09/21/16 was the first day he/she had ever been assigned to the waiting room triage area to triage patients. The RN indicated that patients are normally triaged near the registration area, which is enclosed for privacy. The RN stated that the triage area in the waiting room was being assessed on a trial basis to see if patients could be more easily visualized by an RN and if triage times could be concluded in a more timely manner. The RN indicated that the privacy of the patients had not been discussed prior to his/her assignment to the triage area. The RN indicated that he/she had only triaged three (3) or four (4) patients in the waiting room triage area before it was shut down. When asked if the doors to the treatment areas behind registration were normally closed during patient treatment, the RN stated that normally the nurses shut the door when they have a patient in there. The RN confirmed that you could see into the treatment areas from the waiting room if the doors were not shut.
Observation on 09/21/16 at 9:39 a.m. of the ED department revealed a patient (#9) in room thirteen (13) in the ED treatment area. The patient was observed to be alone in the room. The patient was noted to be in his/her bed holding two (2) blood soaked gauzes. The patient's private area was exposed, and the curtains were observed to be open. When the patient noticed that the surveyor was observing him/her, the patient covered him/herself with the sheet.