. Based on record review and staff interview, it was determined the facility failed to meet the Condition of Participation for Emergency Services. This was determined by the facility's failure to provide care to patients in the Emergency Department (ED) in accordance with acceptable standards of practice. This was evidenced in one (1) of seven (7) ED Patient Record reviews (Patient #8). Findings: The facility failed to establish a written Policy and Procedure for Mortality Reviews for patients who expired in the ED. (See Tag A1104) The facility failed to ensure that the Triage Policy included a mechanism to escalate a change in the patient's condition after the initial triage in one (1) of five (5) patients who expired in the Emergency Department (ED) (Patient #8). (See Tag A1104) The facility failed to ensure that there was a timely Medical Evaluation for ED patients after Triage (Patient #8). (See Tag A1112) The facility's failure to provide care in accordance with acceptable standards of practice caused a delay in diagnostic testing and medical intervention for a patient who expired in the ED. .

. Based on record review, document review and interview, the facility failed to: a) establish a written Policy and Procedure for Mortality Reviews for patients who expired in the Emergency Department (ED), and b) ensure that the Triage Policy included a mechanism to escalate a change in the patient's condition after the Initial Triage in one (1) of five (5) patients who expired in the Emergency Department (ED) (Patient #8). Findings: a) Review of the Medical Record for Patient #8 on 04/09/15 documents that the patient (MDS) dated [DATE] at 5:17PM with a complaint of shortness of breath. The Initial Triage was documented at 5:33PM. The patient was Triaged as a Level 2 - Very Urgent. Review of the Medical Record revealed a three (3) hour delay in a medical screen by the Physician. The Medical Record documented that the patient expired at 11:30 PM on 05/19/14. An Initial Mortality Review by a Physician on 06/30/14 determined that the standard of care was met. A Secondary Review in September 2014 by the facility's "Patient Safety Program", a Team of specially trained RN's, determined the case warranted a second look due to the delay in medical screen and sent the case to the Mortality Review Committee for further review. A review of the Mortality Review Committee Meeting Minutes revealed that the case was placed on the Agenda for October 2014. The case was not reviewed during the October Meeting and was moved to the November Meeting, which was subsequently canceled. According to the Meeting Minutes, the case was again placed on the December 2014 Agenda, but was not reviewed during that Meeting. The case was then moved each month to the next Committee Meeting but was not reviewed until March 2015, six (6) months after being sent to the Mortality Review Committee and ten (10) months after the patient's expiration. Interview on the morning of 04/09/15 with Staff #1 revealed that the case was not reviewed "Because the ED Doctor was unavailable for review". The Mortality Review Committee identified an "Opportunity for Improvement", however, there was no documented evidence of a plan for corrective action. Review of the facility's Medical Staff Bylaws revealed in Subsection 13 titled "The Perinatal Morbidity and Mortality Committee" that the facility had a procedure for Obstetrics and Gynecological Mortality Reviews, but the Bylaws lacked evidence of a Policy and Procedure for other Departmental Mortality Reviews. In an interview in the afternoon of 04/09/15, when asked to review the facility written Policy and Procedure for Mortality Reviews, Staff #3 replied "There isn't one". This was confirmed with Staff #4 at the time of interview. b) Patient #8 was sent by her Cardiologist to the Emergency Department on 05/19/14 at 5:17 PM to rule out a Pulmonary Emboli versus a Deep Vein Thrombosis. Review of the Medical Record on 4/09/15 revealed that the patient was Triaged by the RN in the ED on 05/19/14 at 5:33 PM as a Level 2 - Very Urgent. A Nursing Note at 6:00PM documents the patient with "Respiratory distress. Tachypneic (rapid breathing). Labored respiration noted. Normal respiratory effort." and "Tachycardic (rapid heart rate). Hypertensive (elevated blood pressure)." The patient was placed on three (3) liters of oxygen. The patient was not evaluated by a Physician until 8:12PM. The record lacked documented evidence that the Nurse notified the Physician at the time of Triage, of the patient's initial condition and when the patient's condition required oxygen. The record also lacked documented evidence that the Nurse followed up with the Physician regarding a lack of medical assessment for three (3) hours for a patient Triaged as a Level 2. This finding was confirmed on 04/09/15 in the morning with Staff Members #1 and #2 at the time of record review. Staff #1 stated the patient should have been seen by the ED Physician within one-half (1/2) hour to one (1) hour. The Policy and Procedure, "Triage and Chart Flow" dated 02/13 lacks a procedure to ensure that the Nurses notify the Physican of patients requiring timely evaluation. .

. Based on record review and interview, the facility failed to ensure that there was a timely Medical Evaluation for Emergency Department (ED) patients after Triage in one (1) out of seven (7) ED Medical Records reviewed (Patient #8). Findings: Patient #8 revealed the patient was sent by her Cardiologist to the Emergency Department (ED) on 05/19/14 at 5:17PM to rule out a Pulmonary Emboli versus a Deep Vein Thrombosis. Review of the Medical Record on 04/09/15 revealed that the patient was Triaged by the RN in the ED on 05/19/14 at 5:33PM as a Level 2 - Very Urgent. A Nursing Note at 6:00PM documents the patient with "Respiratory distress. Tachypneic. Labored respiration noted. Normal respiratory effort." and "Tachycardic. Hypertensive." The patient was placed on three (3) liters of oxygen. The patient was not evaluated by a Physician until 8:12PM. The Medical Record lacked documented evidence that the patient received a Medical Evaluation for three (3) hours after Triage, resulting in a delay in diagnostic testing and medical intervention. This finding was confirmed on 04/09/15 in the morning with Staff Members #1 and #2 at the time of record review.