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Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to ensure that care provided in the emergency department was consistent with established facility policies for fourteen of twenty medical records (MR1, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, and MR15).

Findings include:

Review, at approximately 12:05 PM on September 21, 2016, of Policy 83, Patient Rights and Responsibilities, effective January 2016, revealed, "... Care Planning and Delivery - you have the right to: Expect a medical screening exam to determine treatment and emergency procedures to be implemented without unnecessary delay. ..."

Review, at approximately 12:35 PM on September 21, 2016, of Emergency Care Center Patient Presentation Flow Diagram, revised March 8, 2016, revealed that upon arrival to the Emergency Care Center [ECC], the security officer obtains the following information from the patient: time of arrival, first and last name, social security number, date of birth, and reason for visit. If the patient does not present with "priority signs/symptoms," the security officer places the intake label on the registration clipboard log and requests that the patient has a seat in the waiting area. Registration then completes a "Quick Register," of the patient, based upon the information obtained by the security officer. The registration staff member then goes out to the patient to apply an identification bracelet. The triage nurse reviews the registration log and Cerner ED waiting grease board when determining the next patient to triage by highest priority. The triage nurse "determines need to pull patients by their presenting complaint and notifies registrar if someone is being immediately pulled to triage/examination room. Rounds on the waiting room every 30 minutes to identify changes in patient's conditions waiting. Performs Triage and appropriately dispositions patients to correct location. (Note leave patient assigned to the location they are actually located. Etc. If tasked and returned to the waiting room Cerner should reflect the patient as in the waiting room. Triage nurse monitors for changes in condition."

Review, at approximately 10:20 AM on September 22, 2016, of Policy/Procedure 85, Triage, reviewed October 2015, revealed, "... Policy: Every patient, except those arriving by ambulance or in a life-threatening situation, will be evaluated by the triage nurse and assigned a category using the Emergency Severity Index (ESI). ... Patients will be assigned to treatment rooms/areas based on the ESI level and room availability ... Procedure: I. Every patient who comes to the Emergency Care Center is assessed by the triage nurse upon arrival if ambulatory. ... V. The nurse assigned to triage is responsible for identifying those times when patients are waiting excessively (i.e. greater than 30 minutes for triage and requesting assistance. A. Additional staff will work with the Triage Nurse to expedite the initial assessment of those patients who are waiting. VI. If waiting time becomes excessive, the Emergency Care Center physician or CRNP/PAC will be informed and preliminary orders may be obtained when appropriate. VII. Patients held in the waiting area are given first aid by the security/or triage nurse if indicated, i.e. temporary dressing or minor laceration, ice to injured area. VIII. When patients must wait in the waiting room, the Triage Nurse will: A. Inform them to advise the Triage Nurse if their condition changes B. Visualize all patients every 30 minutes or less, paying particular attention to those who have been classified as Level 2 or 3 (See Policy and Procedure#72 for vital sign reassessment information.) C. Document under Waiting Room ½ Hour Rounding Log that Waiting Room Rounds have been done. ..."

Review, at approximately 2:45 PM on September 23, 2016, of Policy 72, Vital Signs Routine, reviewed/revised October 2015, revealed, "... Policy: I. Every patient presenting for treatment in the Emergency Care Center will have his or her vital signs taken as appropriate for their condition, illness or injury. II. All vital sign measurements are recorded on the Emergency Care Center Electronic Medical record. ... IV. Vital signs will be re-assessed according to the patient's condition. Procedure: ... II. All Emergency Care Center patients have initial vital signs taken during the initial assessment and recorded. A. ESI Level 1 and 2 patients will have vital signs every hour or more frequently as deemed necessary by the Emergency Care Center Physician/Registered Nurse. B. ESI Level 3 patients will have vital signs taken and documented every 2 hours or more frequently as deemed necessary by the Emergency Care Center Physician/Registered Nurse C. ESI Level 4 and ESI Level 5 patients will have admission vital signs. D. Discharge vital signs will be documented if the patient is in the Emergency Care Center longer than 2 hours or initial vital signs are out of normal range. E. Any patient with abnormal vital signs must have vital signs repeated in 30 - 60 minutes. ..."

Review of the facility's Emergency Department Control Register, revealed that upon the patient presenting to the Emergency Department, there were approximately eighteen patients present in the Emergency Department.

Review of ED bed count information revealed that the facility has fourteen acute care beds and five fast track beds to care for medical patients.

1. Review of MR1 revealed that the patient presented to the Emergency Department at 12:15 AM on July 28, 2016. Further review revealed that the patient did not have an assessment of vital signs until triage, at 2:04 AM on July 28, 2016.

At approximately 10:00 AM on September 23, 2016, EMP1 confirmed there were no additional vital signs documented between the time of the patient's presentation to the time of triage on July 28, 2016.

2. Review of MR3 revealed that the patient did not have vital signs assessed for approximately 34 minutes following presentation to the facility's ED.

3. Review of MR4 revealed that the patient did not have vital signs assessed for approximately 41 minutes following presentation to the facility's ED.

4. Review of MR5 revealed that the patient did not have vital signs assessed for approximately 51 minutes following presentation to the facility's ED.

5. Review of MR6 revealed that the patient did not have vital signs assessed for approximately one hour six minutes following presentation to the facility's ED.

6. Review of MR7 revealed that the patient did not have vital signs assessed for approximately 37 minutes following presentation to the facility's ED.

7. Review of MR8 revealed that the patient did not have vital signs assessed for approximately 50 minutes following presentation to the facility's ED.

8. Review of MR9 revealed that the patient did not have vital signs assessed for approximately 38 minutes following presentation to the facility's ED.

9. Review of MR10 revealed that the patient did not have vital signs assessed for approximately 48 minutes following presentation to the facility's ED.

10. Review of MR11 revealed that the patient did not have vital signs assessed for approximately one hour three minutes following presentation to the facility's ED.

11. Review of MR12 revealed that the patient did not have vital signs assessed for approximately one hour eighteen minutes following presentation to the facility's ED.

12. Review of MR13 revealed that the patient did not have vital signs assessed for approximately one hour eight minutes following presentation to the facility's ED.

13. Review of MR14 revealed that the patient did not have vital signs assessed for approximately 32 minutes following presentation to the facility's ED.

14. Review of MR15 revealed that the patient did not have vital signs assessed for approximately two hours one minute following presentation to the facility's ED.

15. At approximately 1:15 PM on September 22, 2016, EMP1 confirmed that there was not a Waiting Room Rounding Log completed at the time the patient in MR1 was present in the Emergency Department Waiting Room.