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Based on interviews, review of medical records and other documents, the facility failed to ensure that each patient presenting to the Emergency Department for care is promptly examined. This finding is noted in 5 of 32 patients' records reviewed (Patient #s 1, 2, 3, 4, and 5).

Findings include:

The review of the facility's Emergency Department log on 5/26/15 noted that Patient #1 and Patient #2 left before they were triaged.

Patient #1, a 63 year-old male was noted to have arrived in the ED on 4/7/15 and was logged in by the registrar at 2:14 PM. Similarly, Patient #2, a 42 year-old female arrived on 4/7/15 at 5:18 PM. The medical record shows that both patients departed the Emergency Department prior to a triage assessment.

The records for Patient #1 and #2 lacked an immediate assessment upon their arrival in the ED to determine the priority for medical screening evaluation. The records lacked information on why Patient #1 and Patient #2 sought emergency medical treatment. In addition, the time of departure of these patients were not indicated in their medical record.

During the tour of the Emergency Department on 5/26/15 at about 11:15 AM, three of five patients interviewed have been waiting between 45 minutes to 1 ½ hours for triage assessments.

At interview with Patient #3 in the ED Waiting Room on 5/26/15 at 11:15 PM, he stated he has waited over one hour and has not been triaged.

Patient #4 on 5/26/15 at 11:17 AM reported she has been waiting one hour and a half for triage.

The mother for Patient #5 at interview on 5/26/15 at 11:20 AM reported her daughter had not been triaged. She stated they have waited 45 minutes after registration.

At interview with Staff #1 during the ED tour on 5/26/15 at 11:21 AM, she confirmed Patient #s 3, 4, and 5 have undergone mini registration, but have not been triaged. She stated a patient upon arrival is directed to the Registrar who obtains the patient's name, date of birth, and the reason for the visit. The information from the patient is immediately available to the triage nurse who determines the order in which patients are called to triage. She stated that a face-to-face assessment of the patient is conducted only at the time of triage.

The facility failed to implement its policy for prompt assessment of each patient upon arrival in the ED.

Review of the facility's policy titled "Emergency Department Triage" last revised in December 2012 notes, "The purpose of triage is to identify patients who require immediate, definitive care. It is the process by which patients are sorted and classified according to the type and urgency of their conditions based on a rapid focused assessment of each patient's chief complaint". In addition, the policy titled "Assessment of Patients in the Emergency Department" notes "An initial triage assessment is performed by a registered nurse upon a patient's arrival in the Emergency Department.

Based on interviews, review of medical records and other documents, it was determined the facility failed to ensure that each patient in the Emergency Department receives appropriate medical screening examination and treatment. This finding was noted in 1 of 32 medical records reviewed (Patient #6).

Findings include:

Patient #6 is a 32 year-old female who presented to the Emergency Department on 3/29/15 at 5:18 PM with a chief complaint of shoulder abscess. The patient had multiple medical conditions including chronic hepatitis C, hypertension, diabetes mellitus, hypothyroidism, recurrent abscesses, nephropathy, End Stage Renal Disease, and was on dialysis three times weekly.

Physician assessment of the patient documented on 3/29/15 at 11:03 PM notes a 6 centimeters (cm) x 8 cm abscess on the patient's right arm and the back of her head. The patient was started on antibiotics on 3/29/15 at 11:32 PM and she later underwent an incision and drainage of the abscess at about 12:26 AM on 3/30/15.

The facility failed to provide ongoing evaluation and timely treatment of the patient's medical condition. An elevated glucose level of 268 milligrams per deciliter (mg/dl) taken on 3/29/15 at 6:50 PM was not addressed, consequently the patient's glucose further elevated to 486 mg/dl on 3/30/15 at 5:09 AM.

Laboratory tests ordered by the physician on 3/30/15 between 8:57 to 8:58 PM included Complete Blood Count, Basic Metabolic panel, Liver tests, Lipase, Magnesium, Prothrombin time, APTT, Phosphorous, Blood culture, Urinalysis and urine culture were not implemented.

There was no indication the patient was continuously assessed and monitored after receiving multiple pain medications. The Medication Administration Record revealed Morphine 4 milligrams (mg) intravenous (IV) injection ordered on 3/29/15 at 8:58 PM was administered on 3/29/15 at 11:39 PM. Hydromorphone 1 mg IV and Diphenhydramine 50 mgs IV were both administered on 3/29/15 at 11:44 PM. In addition, a second dose of Morphine 4 mg IV was documented by the nurse to have been administered on 3/29/15 at about 11:43 PM. The patient's vital signs were last recorded on 3/29/15 at 10:49 PM prior to pain management intervention.

The patient was found unresponsive on 3/30/15 at 4:58 AM and pronounced dead at 5:26 AM following failed resuscitation efforts.

At interview with Staff #2, on 5/27/15 at 12:15 PM, he stated at the time of patient's presentation on 3/29/15, the Emergency Department was exceedingly crowded, a patient was being coded and patients' care was being transferred to the incoming shift. He stated he recognized there was a lack of communication that resulted in untimely implementation of laboratory test orders. He also added that Patient #6's vital signs could have been monitored more frequently based on patient's condition.

At interview with Staff #1 on 5/27/15 at 2:20 PM, she stated that a glucose level of 268 mg/dl, although abnormal, was not a critical value that requires emergency treatment. Regarding vital signs monitoring, Staff #1 stated the first dose of Morphine was given shortly after it was ordered on 3/29/15 at 8:58 PM and not at 11:39 PM as documented in the Medication Administration Record. Regarding patients triaged as ESI level -3, Staff #1 stated that vital signs are monitored, at a minimum, every four hours in accordance with the Emergency Department policies.

Review of the Emergency Department policy titled "Assessment of Patients in the Emergency Department" last revised in March 2012, notes "All level three (3) patients should have a brief evaluation within 2 hours by the MD to determine the patients' stability. If stable vital signs will be repeated every (4) four hours until admission, discharge, or unless written MD orders specify otherwise".

The patient's record revealed lack of vital signs for over six (6) hours before the patient was found unresponsive on 3/30/15 at 4:58 AM.