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.

DENVER HEALTH & HOSPITAL AUTHORITY 777 BANNOCK ST DENVER, CO 80204 Sept. 27, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.13, PATIENT RIGHTS, was out of compliance.


A-0118 The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The facility failed to ensure patient concerns were investigated and resolved in accordance with the facility's grievance process in 4 of 8 grievances reviewed (Patients #10, A, B, and C).

A-0143 The patient has the right to personal privacy. The facility failed to ensure the personal privacy for 5 of 5 patients who received care while placed in hall beds located in the Emergency Department (ED) corridors (Patients #9, #11, #13, #14 and #15). This resulted in instances in which patients were asked personal questions, received physical assessments, nursing care, blood draws, and were provided education and discharge instructions without processes in place to ensure their privacy.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interviews and document review, the facility failed to ensure patient concerns were investigated and resolved in accordance with the facility's grievance process in 4 of 8 grievances reviewed (Patients #10, A, B, and C).

Findings Include:

Policy:

The Concern/Complaint/Grievance Policy read, dedication to providing quality care and service to patients required an effective mechanism for resolving patient grievances. The goal was to be responsive and foster open communication with patients at all levels within the organization with the objective of resolving complaints expediently through appropriate problem solving actions.

A patient grievance was a written or verbal complaint (when the verbal complaint about patient care was not resolved at the time of the complaint by staff present) by a patient regarding the patient's care, abuse or neglect. If a situation continued to be a concern, the concern was submitted to the patient advocate by the next working day to assist in the resolution of the issue. A Level I investigation was the initial investigation completed by the patient advocates. A Level II investigation was initiated by the Conflict Resolution Committee if the patient was not satisfied with the results of the Level I investigation.

1. The facility failed to investigate a grievance submitted by the patient's representative.

a. Review of the Safety Intelligence: Patient Relations Complaints Manager Form (complaint form) revealed the daughter of Patient A called the facility (Hospital A) and spoke with Patient Advocate Supervisor (Supervisor) #17 on 4/6/18. The patient's daughter stated she brought her mother to the emergency department (ED) and the patient was released because the hospital did not have another bed at the time of service. The daughter reported the staff were not helpful and treated her mother poorly. The daughter stated she then took her mother to a different hospital (Hospital B) where the patient was admitted for a kidney infection. The daughter thought the hospital admission may have been prevented if the ED provided better care for her mother.

Review of the complaint form revealed Supervisor #17 spoke with the daughter on 4/9/18 and the patient's daughter agreed to gather the medical records from the patient's admission from Hospital B and provide the records to Supervisor #17 for further review.

Review of the complaint form revealed the case was closed on 4/9/18, and a final letter dated 4/6/18 was sent to the patient stating the investigation found the "care and diagnosis was appropriate."

b. An interview was conducted on 9/27/18 at 11:53 a.m. with Supervisor #17 who reviewed the complaint form for Patient A. Supervisor #17 stated the case was considered a grievance because it involved a complaint about patient care. Supervisor #17 stated he had requested the daughter obtain the medical records from Hospital B; however, the daughter never provided the records so the case was closed. Supervisor #17 stated the case should have been forwarded to the ED for review, but it was not. He stated it was not possible to determine whether the patient was seen in the ED by reviewing the complaint form. Supervisor #17 stated he sent a letter to the daughter stating the care was appropriate, but he did not know how that was determined.

c. On 9/27/18 at 7:57 a.m., the medical record was requested for Patient A's visit associated with this grievance. At 1:00 p.m., Quality Coordinator (Coordinator) #18 stated she was unable to locate a medical record for Patient A for this visit. Coordinator #18 was asked to check the ED log. She stated the facility had no record of Patient A's visit.

d. On 9/27/18 at 2:10 p.m., an interview was conducted by telephone with Chief Experience Officer (Officer) #20. Patient Advocate Supervisors #17 and #19 also participated in the interview. Officer #20 was surprised to learn there was not a medical record for Patient A's visit, and the ED manager had not reviewed the grievance. Officer #20 stated she was concerned the daughter was told the care was appropriate when there was no documentation how the care was investigated.

2. The facility failed to follow the process outlined in the grievance policy; specifically, grievances were not escalated to a Level 2 review when the patient or patient representative was not satisfied with the Level 1 investigation.

a. Review of the complaint form dated 7/9/18 revealed Patient B's mother contacted the facility with concerns about the care of her daughter and the newborn during childbirth. The newborn had developed an infection which the patient's mother was concerned may have been related to patient care. The patient advocate determined the concern was a grievance and forwarded the concern to Physician #22 who provided his response. Patient Advocate #23 sent a letter dated 7/18/18 to the patient, which stated the care provided had been appropriate. Review of the complaint form stated the patient was dissatisfied with the result of the investigation.

An interview was conducted on 9/27/18 at 11:53 a.m. with Supervisor #17 who stated the grievance was not escalated to Level 2, but it should have been so the patient was able to receive a satisfactory response.

On 9/27/18 at 2:10 p.m., an interview was conducted by telephone with Chief Experience Officer (Officer) #20. Patient Advocate Supervisors #17 and #19 also participated in the interview. Supervisor #19 stated a Level 2 investigation would have been recorded on the complaint form if conducted. She stated the purpose of grievance investigations was to ensure the facility was meeting the needs of the patients. Level 2 investigations occurred when the patient needs had not been met, and the patient requested a review. Supervisor #19 was unable to locate any documentation a Level 2 investigation was offered to Patient B.

Officer #20 stated Level 2 investigations were discussed in weekly meetings to ensure patient concerns were addressed. Officer #20 stated her expectation was, if patients were telling the patient advocate they were not satisfied, then the grievance needed to be escalated. Officer #20 stated she did not regularly review investigations to ensure the grievance policy was being implemented correctly.

b. Review of the complaint form revealed Patient #10 called the patient advocate on 8/22/18, while he was admitted to the hospital, with concerns regarding his plan of care. On 8/22/18 at 12:57 p.m., Patient Advocate #24 went to Patient #10's hospital room to discuss his concerns. Patient #10 began to argue with Patient Advocate #24 so the patient advocate left the unit. Review of the complaint form revealed on 8/23/18, Patient Advocate #24 spoke with a Registered Nurse (RN) from the unit the patient had received care on.. The RN stated the patient was pleased with his move to the psychiatric unit. As a result, Patient Advocate #24 closed the case but noted the patient was dissatisfied.

Review of the nursing and provider progress notes from the medical record from Patient #10's admission to the psychiatric unit revealed Patient #10 repeatedly requested to see a patient advocate throughout his 20 day admission. For example, on 8/25/18 at 11:20 a.m., Physician #25 documented a Significant Event (note) where he provided a second opinion to authorize administration of emergency psychiatric medications to Patient #10. The note documented Patient #10 was perseverant on seeing a patient advocate. However, Patient #10 had previously been hostile with the patient advocate who did not feel safe with him. Patient #10 was informed the patient advocates were not present over the weekend, and a patient advocate would meet with him on Monday.

On 8/27/18 at 10:30 a.m., Registered Nurse (RN) #26 documented a Nursing Note which stated she had contacted the patient advocate who was going to evaluate whether a patient advocate was able to see the patient that day. There was no documentation the patient advocate contacted the patient on 8/27/18. Additional review of the nursing and provider progress notes revealed Patient #10 continued to request access to the patient advocate. The medical record revealed Patient #10 was discharged two weeks later, on 9/10/18. There was no documentation Patient #10 ever spoke with a patient advocate to assist him with resolving his concerns.

On 9/27/18 at 2:10 p.m., an interview was conducted by telephone with Officer #20. Patient Advocate Supervisors #17 and #19 also participated in the interview. Officer #20 was familiar with this grievance. She stated she was aware there had been requests for the patient advocate to meet again with Patient #10 and thought a meeting had occurred.

Supervisor #19 reviewed the complaint form and stated there should have been a process for the patient advocate to circle back and address the patient's concerns. Supervisor #19 stated the complaint form showed the patient was pleased with being moved to the psychiatric unit but did not identify any of his other concerns or his repeated requests to meet with a patient advocate. Officer #20 stated she expected patient care staff to contact her whenever a patient was requesting to talk with a patient advocate. Officer #20 stated when patients requested her staff come back, they should have returned.

c. Review of the complaint form for Patient C revealed he called the patient advocate's office on 4/24/18 concerned he was kept beyond the expiration of his three day mental health hold. The patient advocate classified the concern as a grievance and forwarded it to the physician for review. The physician responded the following day. Patient Advocate #24 then wrote a letter dated 4/25/18 to Patient C explaining the patient was currently on a Short Term Certification to ensure his safety. It was documented on the complaint form that Patient C was dissatisfied with the resolution. There was no documentation Patient C was offered a Level 2 investigation.

On 9/27/18 at 2:10 p.m., an interview was conducted by telephone with Officer #20. Patient Advocate Supervisors #17 and #19 also participated in the interview. Supervisor #19 reviewed the complaint form and stated this grievance was not escalated to Level 2, and there was no documentation a Level 2 investigation was offered to Patient C.

Officer #20 stated her staff was not consistently following the process for escalating grievances according to facility policy. Officer #20 stated her team should have begun auditing grievances to ensure the process was being followed correctly.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, interviews and record review, the facility failed to ensure the personal privacy for 5 of 5 patients who received care while placed in hall beds located in the Emergency Department (ED) corridors (Patients D, E, F, #9, #11).

This failure resulted in instances in which patients were asked personal questions, received physical assessments, nursing care, blood drawn, and were provided education and discharge instructions without processes in place to ensure their privacy.

Findings include:

Facility policies:

The Patient Rights and Responsibilities policy read, all patients have the right to receive care and treatment that was respectful, recognizes the person's dignity, cultural and personal values and religious beliefs, provides for personal privacy to the extent possible during the course of treatment, and promotes a positive self-image.

The Nursing Guidelines of Care for Adult Emergency Department Patients policy read, all patients who are seen in the ED would have a complete set of vital signs documented upon initiation of care. Vital signs include heart rate, blood pressure, pulse oximetry, temperature and pain assessments. All patients that verbalize suicidal ideation must have a 1:1 sitter (designated staff member) with direct visualization and within arm's reach at all times.

1. The ED staff provided care to patients in hall beds without ensuring a uniformed and approved process was in place to protect patients' personal privacy and confidentiality.

a. On 9/24/18 at 12:12 p.m., a tour of the ED was conducted with Quality Registered Nurse (Quality RN) #3 and ED Manager (Manager) #1. According to Manager #1, the ED was divided into 4 areas: medical ED, trauma ED, behavior health, and an observation area. In total the ED had 57 beds. Posted on the wall in the trauma ED area were designated locations for surge beds one through ten. Posted on the wall in the medical ED area were designated locations for surge beds 11 through 20. Manager #1 stated the surge and hall beds were the same and the terms would be used interchangeably.

During the tour, Manager #1 explained hall beds were used when the ED volume of patients was more than the capacity of beds at which time patients were placed in hall beds next to the nurses' station. Additionally, Manager #1 stated the use of hall beds was up to the charge nurse discretion and there was no written criteria or policies to follow.

b. During a tour of the ED on 9/26/18 at 11:40 a.m., an interview with Unit Clerk (UC) #5 was conducted. UC #5 stated she was able to always see and hear hall bed patients. UC #5 stated patients had conversations with nursing staff, pharmacy staff and physicians while in hall beds and had their vital signs monitored as well as.

c. Review of Patient #9's medical record revealed the patient arrived to the emergency department on Monday, 9/24/18 at 10:59 a.m. and was placed in hallway bed #2. The chief complaint was documented as suicide attempt.

At 11:14 a.m. the provider documented Patient #9 had a history of mental illness and was placed on a mental health hold for suicidal ideations.

At 11:48 a.m., Patient safety checks were conducted. The patient remained in police custody with police at the bedside.

At 12:03 p.m., the psychiatric nurse documented an assessment of Patient #9 to include the patient was subdued and minimally cooperative with her interview. Additionally, the RN documented the patient reported a history of mental illness with ongoing depression. The patient remained indifferent about being alive.

At 12:17, Patient #9 was moved from the hallway into an emergency department room. This was more than an hour after the patient arrived at the ED and five minutes after the survey team began a tour and the patient was observed in the ED hallway bed.

d. Review of Patient D's patient care timeline revealed the patient arrived to the emergency department (ED) on 9/7/18 at 2:26 p.m. According to the triage note, the patient reported right neck pain. The triage note further documented ambulance personnel found the patient to have an increased heart rate, blood pressure and rate of breathing with methamphetamine found on the patient, which the patient stated he had used. The patient was involved in a car and foot chase with the police prior to arrival.

At 2:26 p.m., on arrival, Patient D was placed in hall bed #15. At 2:57 p.m., Patient D's vital signs were obtained with a blood pressure of 154/88 and a heart rate of 101.

At 2:59 p.m., Patient D stated he had acute, aching, right neck pain rated on a pain scale of five out of 10.

At 3:01 p.m., the registered nurse (RN) did a focused assessment and documented Patient D's airway, breathing, circulation and disability were all within defined limits.

At 5:11 p.m., Patient D continued to be located in hallway bed #15. The RN documented the patient was notified of the plan of care.

At 8:51 p.m., Patient D was discharged from the hallway bed.

On review of the care time line, there was no documentation Patient D was placed in an ED room. He was in the ED for just under seven hours and received all of his care in the hallway bed.

e. Review of Patient E's patient care timeline revealed the patient arrived at the ED on 8/31/18 at 4:22 p.m. with a chief complaint of alcohol intoxication. On arrival at 4:33 p.m., Patient E was placed in hallway bed #2.

At 4:49 p.m., according to the triage note, Patient E was found in a grassy area and only responsive to noxious stimuli. The note further documented the patient was awake, alert and oriented with noxious stimuli, was drowsy and admitted to drinking alcohol and using marijuana today.

At 4:57 p.m., Patient E's vital signs were obtained with a blood pressure of 120/72 and a heart rate of 85. The patient's oxygenation saturation was documented at 98% on oxygen via a nasal cannula at 4 liters per minute.

At 5:02 p.m., the RN did a focused assessment and documented Patient E's airway, breathing, circulation were all within defined limits and the patient was drowsy. The patient's oxygenation saturation was documented as 98% with 85% on room air.

At 8:02 p.m., the provider documented the patient was able to be discharged to an outpatient setting for continued care.

At 8:44 p.m., the patient was discharged .

On review of the care time line, there was no documentation Patient E received any of his care in an ED room. He was in the ED for a total of four hours and received all of his care, to include discharge instructions and oxygen therapy while in a hallway bed.

f. Review of Patient F's patient care timeline revealed the patient arrived to the ED on 9/14/18 at 12:38 p.m. According to the triage note the patient was brought in by ambulance after being involved in a motor vehicle crash and reported lower back pain. On arrival, Patient F was placed in hallway bed #1.

At 12:51 p.m., the RN did a focused assessment and documented Patient F's airway, breathing, circulation.

At 12:54 p.m., lab work was obtained and medication for pain was given.

At 2:56 p.m., Patient F was discharged home.

On review of the patient care timeline, there was no documentation Patient F received any of his care, to include nursing and physician assessments and discharge instructions in a manner which provided and protected the patients right to personal privacy, as Patient F received all of his care in hallway bed #1.

Similar findings were found for Patient #11 who was seen in the emergency department on Sunday, 9/23/18 at 9:19 p.m.

g. On 9/27/18 at 10:40 a.m., an interview was conducted with RN #8 who was the charge nurse for the ED. RN #8 stated the ED was inundated with alcoholic and incarcerated patients and assigned patients to a hall bed when the ED reached capacity. RN #8 stated the most utilized hall beds were hall beds #2, #3 and #4 and were located in the busiest area of the ED. RN #8 stated this was so more staff could monitor the patients placed in those hallway beds.

RN #8 stated he was trained on the job for the criteria in which to place patients in a hall bed. Furthermore, he stated suicidal or sexual assault patients were not appropriate for placement in a hall bed.

However, record review for Patient #9, revealed he arrived at the ED via ambulance with a chief complaint of suicide attempt and was placed on a mental health hold for suicidal ideations.

RN #8 stated the majority of hall bed utilization was for patients who were ready to be discharged and transported to jail or for intoxicated patients.

However, record review showed 2 of 5 patients reviewed who received care in the hall way were no ready for discharge when they were receiving the care (Patients D and F).

RN #8 stated he maintain personal privacy with blankets while a patient was in a hall bed. Additionally, he stated hall bed patients would be use the public restroom or the restroom in an empty ED room. RN #8 stated patient care activities such as triage, nursing assessments, suicide assessments, physician examination and medical history assessments were all performed while a patient would be located in the hallway.

h. On 9/26/18 at 11:51 a.m., an interview with RN #6 was conducted. RN #6 stated she was frequently a charge nurse in the ED. RN #6 stated she would use a hall bed to monitor an intoxicated patient until they were sober. RN #6 stated the advantage of placing a patient in a hall bed was she was able to start patient care to include RN assessment, physician assessment, lab work and radiological imaging.

RN #6 stated hall bed #2 was used most frequently so all staff could see them and assist in their care. RN #6 stated, due to the volume of people passing the area, other staff passing by could help monitor those hallway bed patients. RN #6 stated she would ensure personal privacy by being cognizant and asking general personal questions when they were in a hall bed and waiting until they were assigned an ED room prior to asking more specific personal questions.

RN #7 arrived to the interview with RN #6 and added he also filled in as a charge nurse. RN #7 stated there was usually a large volume of people passing by the hallway bed area. RN #7 further stated initial care was the same for a patient assigned to a hallway bed or an ED room and would include lab draws and assessments. RN #7 stated he would still ask assessment questions to a patient in a hall bed. However, RN #7 explained he would try to be cognizant of patient privacy when asking questions. RN #7 stated he used sheets to provide physical personal privacy to a hall bed patient. RN #7 stated physician would pull sheets up to perform physical inspections of patients' legs or ankles in a hall bed, but he would take a patient into a room to perform a pelvic exam. RN #7 further stated a hall bed patient would have to ambulate to an ED room or public bathroom if they requested to use the bathroom.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.41 PHYSICAL ENVIRONMENT, was out of compliance.

A-0725 The extent and complexity of facilities must be determined by the services offered. The facility failed to ensure the emergency department (ED) was appropriately utilized to accommodate for the volume of patients who presented to and were treated in the emergency department by routinely utilizing hall beds.
VIOLATION: COMPLEXITY OF FACILITIES Tag No: A0725
Based on interviews and document review the facility failed to ensure the emergency department (ED) was utilized to accommodate the extent and volume of patients who presented to and were treated in the ED.

Findings include:

1. The facility failed to ensure the emergency department (ED) was appropriately utilized to accommodate for the volume of patients who presented to and were treated in the emergency department by routinely utilizing hall beds.

a. Review of Patient #9's medical record revealed the patient arrived to the emergency department on Monday, 9/24/18 at 10:59 a.m. and was placed in hallway bed #2. The chief complaint was documented as suicide attempt.

At 11:14 a.m. the provider documented Patient #9 had a history of mental illness and was placed on a mental health hold for suicidal ideations.

At 11:48 a.m., Patient safety checks were conducted. The patient remained in police custody with police at the bedside.

At 12:03 p.m., the psychiatric nurse documented an assessment of Patient #9 to include the patient was subdued and minimally cooperative with her interview. Additionally, the RN documented the patient reported a history of mental illness with ongoing depression. The patient remained indifferent about being alive.

At 12:17, Patient #9 was moved from the hallway into an emergency department room. This was more than an hour after the patient arrived at the ED and five minutes after the survey team began a tour and the patient was observed in the ED hallway bed.

b. Review of Patient D's patient care timeline revealed the patient arrived to the emergency department (ED) on 9/7/18 at 2:26 p.m. According to the triage note, the patient reported right neck pain. The triage note further documented ambulance personnel found the patient to have an increased heart rate, blood pressure and rate of breathing with methamphetamine found on the patient, which the patient stated he had used. The patient was involved in a car and foot chase with the police prior to arrival.

At 2:26 p.m., on arrival, Patient D was placed in hall bed #15. At 2:57 p.m., Patient D's vital signs were obtained with a blood pressure of 154/88 and a heart rate of 101.

At 2:59 p.m., Patient D stated he had acute, aching, right neck pain rated on a pain scale of five out of 10.

At 3:01 p.m., the registered nurse (RN) did a focused assessment and documented Patient D's airway, breathing, circulation and disability were all within defined limits.

At 5:11 p.m., Patient D continued to be located in hallway bed #15. The RN documented the patient was notified of the plan of care.

At 8:51 p.m., Patient D was discharged from the hallway bed.

On review of the care time line, there was no documentation Patient D was placed in an ED room. He was in the ED for just under seven hours and received all of his care in the hallway bed.

c. Review of Patient E's patient care timeline revealed the patient arrived at the ED on 8/31/18 at 4:22 p.m. with a chief complaint of alcohol intoxication. On arrival at 4:33 p.m., Patient E was placed in hallway bed #2.

At 4:49 p.m., according to the triage note, Patient E was found in a grassy area and only responsive to noxious stimuli. The note further documented the patient was awake, alert and oriented with noxious stimuli, was drowsy and admitted to drinking alcohol and using marijuana today.

At 4:57 p.m., Patient E's vital signs were obtained with a blood pressure of 120/72 and a heart rate of 85. The patient's oxygenation saturation was documented at 98% on oxygen via a nasal cannula at 4 liters per minute.

At 5:02 p.m., the RN did a focused assessment and documented Patient E's airway, breathing, circulation were all within defined limits and the patient was drowsy. The patient's oxygenation saturation was documented as 98% with 85% on room air.

At 8:02 p.m., the provider documented the patient was able to be discharged to an outpatient setting for continued care.

At 8:44 p.m., the patient was discharged .

On review of the care time line, there was no documentation Patient E received any of his care in an ED room. He was in the ED for a total of four hours and received all of his care, to include oxygen therapy while in a hallway bed.

d. Review of Patient F's patient care timeline revealed the patient arrived to the ED on 9/14/18 at 12:38 p.m. According to the triage note the patient was brought in by ambulance after being involved in a motor vehicle crash and reported lower back pain. On arrival, Patient F was placed in hallway bed #1.

At 12:51 p.m., the RN did a focused assessment and documented Patient F's airway, breathing, circulation.

At 12:54 p.m., lab work was obtained and medication for pain was given.

At 2:56 p.m., Patient F was discharged home.

There was no documentation Patient F received any of his care in an ED room. He was in the ED for a total of two hours and received all care and services while in the hallway.

Similar findings were found for Patient #11 who was seen in the emergency department on Sunday, 9/23/18 at 9:19 p.m.

e. On 9/24/18 at 12:12 p.m., a tour of the ED was conducted with Quality Registered Nurse (Quality RN) #3 and ED Manager (Manager) #1. According to Manager #1, the ED was divided into 4 areas: medical ED, trauma ED, behavior health, and an observation area. In total the ED had 57 beds. Posted on the wall in the trauma ED area were designated locations for surge beds one through ten. Posted on the wall in the medical ED area were designated locations for surge beds 11 through 20. Manager #1 stated the surge and hall beds were the same and the terms would be used interchangeably.

During the tour, Manager #1 explained hall beds were used when the ED volume of patients was more than the capacity of beds at which time patients were placed in hall beds next to the nurses' station. Additionally, Manager #1 stated the use of hall beds was up to the charge nurse discretion and there was no written criteria or policies to follow. She stated she was not tracking the use of hall beds, therefore was unaware of how often they were utilized.

As the facility was not tracking hall bed utilization the survey team requested a focused sample of data for review. The sample was for four Fridays from 8/31/18 to 9/21/18 of patients who had received care in the hallway. On 9/27/18 at 12:10 p.m. Director #2 provided an email in which ED Manager #1 had compiled a list of those patients who spent time in a hall bed. The email noted each Friday hallway beds were utilized. Specifically, on 8/31/18 11 patients were admitted to ED hallway beds, on 9/7/18 five patients, on 9/14/18 nine patients and on 9/21/18 six patients.

Manager #1 stated patients would be placed in a hallway bed waiting for a room to be cleaned, waiting to transfer to an inpatient room, or a patient in custody waiting to transfer to the jail. However, this was in contrast to the medical record review for Patients #9, #11, A, and F.

f. On 9/27/18 at 10:40 a.m., an interview was conducted with RN #8 who was the charge nurse for the ED. RN #8 stated the ED was inundated with alcoholic and incarcerated patients and assigned patients to a hall bed when the ED reached capacity. RN #8 stated the most utilized hall beds were hall beds #2, #3 and #4.

RN #8 stated he was trained on the job for the criteria in which to place patients in a hall bed. Furthermore, he stated suicidal or sexual assault patients were not appropriate for placement in a hall bed.

However, record review for Patient #9, revealed he arrived at the ED via ambulance with a chief complaint of suicide attempt and was placed on a mental health hold for suicidal ideations.

RN #8 stated the majority of hall bed utilization was for patients who were ready to be discharged and transported to jail or for intoxicated patients.

However, record review showed 2 of 5 patients reviewed who received care in the hall way were no ready for discharge when they were receiving the care (Patients D and F).

h. On 9/26/18 at 11:51 a.m., an interview with RN #6 was conducted. RN #6 stated she functioned as a charge nurse in the ED. RN #6 explained hall beds were used most frequently for patients brought in by ambulance when the ED was over capacity, especially for monitoring intoxicated patients until sober.

i. On 9/26/18 at 4:16 p.m., an interview with the Chief Quality Officer (CQO) #11 was conducted. CQO #11 stated he had seen ED visit numbers increase, along with the hospital reaching capacity status more frequently, which required the use of hall beds in the ED to be more frequent. Additionally, CQO #11 explained the only circumstance to place a patient in a hall bed was when the inpatient hospital rooms were full and there were no designated ED rooms available for a patient. CQO #11 stated he did not feel hall beds were being used in the ED routinely.

It was not evident how this was determined as the facility did not track the use of the hall beds in the ED.

On 9/27/18 at 11:17 a.m., a follow up interview with CQO #11 was conducted. CQO #11 stated the facility had been meeting weekly at the executive level and through quality meetings to work on strategies related to patient flow within the hospital. CQO #11 stated he did not like patients spending a lot of time in the ED or in hall beds, but felt the facility was doing all they could. CQO #11 stated since the facility was not tracking the use of hall beds there was a difficulty obtaining data. However, CQO #11 was able to present data in which he stated for the last five Fridays, 5% of time spent in the ED was in a hall bed. Additionally, CQO #11 stated hall beds were used more often from 2:00 p.m. to 3:00 a.m., and most frequently on Fridays.

However, record review showed 2 of 5 patients reviewed who received care in an ED hall bed were admitted on a Sunday and Monday (Patients #9 and #11).

j. On 9/26/18 at 5:06 p.m., a follow up interview with Director of Patient Safety and Quality (Director) #2 was conducted. Director #2 stated the facility had no policy for the use of hall beds in the ED. Director #2 stated the use of hall beds was a clinical judgement by the ED staff. Director #2 stated the facility would not routinely use the hall beds if the facility were not routinely at capacity.

Review of the Executive Committee for Patient Safety and Quality meeting minutes from April 2018 to August 2018 revealed no documentation of discussion of hospital patient flow issues or resolution related to the use of ED hallway beds.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and document review, the facility failed to provide patient specific discharge instructions and teaching for post-hospital care in 1 of 1 patients discharged with a Foley catheter (Patient #3).

Findings Include:

Policy:

The Patient Discharge policy read, education was to be provided to the patient/family as identified throughout the admission to ensure necessary patient teaching has occurred. [Physicians and Allied Health Professionals are to] assess the patient/family's understanding of the discharge instructions using return demonstration, teach back, or verbalization of instructions.

Reference:

Indwelling Urinary Catheter Care, Adult Special Instructions include: how to wear your catheter, how to care for your skin, how to clean your catheter and your skin, how to care for your drainage bag, how to prevent infection and other problems, when to contact a health care provider and when to get help immediately.

1. The facility failed to ensure Patient #3 was given discharge instructions and teaching regarding post-hospitalization Foley catheter care.

a. Review of Patient #3's medical record revealed he was admitted on [DATE]. According to a urology progress note dated 6/19/18 at 4:08 p.m., Physician #14 documented Patient #3 would be discharged with a Foley catheter which would be removed after discharge in the urology clinic.

Review of Patient #3's discharge summary revealed at 6/28/18 at 1:07 p.m., Physician #15 documented Patient #3 was discharged with a Foley catheter, which would be removed in the outpatient urology clinic, along with a urethral stent which had been placed during his stay.

b. On 6/27/18 at 11:21 a.m., Physical Therapy Assistant (PTA) #16 documented she discussed Patient #3's Foley catheter with the attending medical team and the nurse. She documented the staff needed to either remove the Foley catheter prior to discharge or provide teaching to Patient #3 on post hospitalization care..

c. An interview was conducted with Registered Nurse (RN) #12 on 9/27/18 at 9:03 a.m., RN #12 stated patients being discharged with a Foley should receive teaching on how to care for them, clean them and the signs and symptoms of an infection. She stated if staff were aware the patient would be discharged with a Foley catheter in the weeks prior to discharge, the teaching should be started and continuously documented during that time. She stated the patient should assist in the care so staff can assess the patient's ability to care for the catheter. She stated documentation of the teaching and the patient's response should be found in nursing notes. She also stated any teaching provided at the time of discharge regarding Foley care should be documented in the discharge instructions or in nursing discharge note.

Review of Patient #3's medical record revealed no such documentation. There was no documentation of any education regarding care of a Foley catheter or an assessment of Patient #3's ability to care for a Foley during Patient #3's stay, nor in his discharge instructions.

d. On 9/27/18 at 10:13 a.m., an interview was conducted with RN #13. RN #13 stated patients being discharged with Foley catheters should be educated on how to clean the catheter site and how to empty the drainage bag. She stated any teaching should be documented. RN #13 stated if the teaching was not documented, there was no way of ensuring it was completed.

RN #13 was asked to review Patient #3's medical record for evidence Patient #3 was educated on how to clean and care for his Foley catheter, how to empty the drainage bag and the signs and symptoms of an infection. RN #13 stated she was unable to find any documentation of this teaching during Patient #3's hospital stay. RN #13 was also unable to find any evidence Patient #3 was assessed to determine his ability to care for his Foley. Further, she was unable to find any evidence of education in his discharge instructions or in the nursing discharge note.

This was in contrast to facility policy which stated education was to be provided to the patient/family as identified throughout the admission to ensure necessary patient teaching has occurred. [Physicians and Allied Health Professionals are to] assess the patient/family's understanding of the discharge instructions using return demonstration, teach back, or verbalization of instructions.

RN #13 stated the risk of patients not being educated on how to care for and clean their Foley catheter was infection, possibly a severe one.

e. Record review revealed Patient #3 was readmitted [DATE] for a catheter associated urinary tract infection.