Based on observation and interview, the facility failed to display conspicuously in the Emergency Department the Emergency Medical and Treatment Act (EMTALA) signage that specified the rights of patients to examination and treatment of emergency medical condition, and for women in labor Findings include: During tour of the Emergency Department on 01/18/18 at approximately 2:00 PM, there was no EMTALA signage posted at the emergency room walk in entrance, Ambulance entrance, the waiting and treatment areas. The EMTALA signage posted behind the information desk in the Adult Mini-Registration/Pre-triage area was not easily visible to patients. Another sign posted by the Registration Desk in English and Spanish was in small print and above eye level, which made it difficult to read. During interview with Staff U, Coporate Director, on 1/8/18 at approximately 2:00 PM, she acknowledged findings.

Based on medical record review, document review and interview, the facility failed to maintain an accurate Emergency Department (ED) log. Specifically, the disposition of each patient was not accurately documented in the log. Findings include: Review of the ED log for 10/1/2017 revealed the disposition of Patient #2 was noted as "01- quick reg". However, the review of the patient's medical record revealed the patient was treated and discharged home. The log for 1/11/2018 revealed that Patient #14 walked out of the ED. Review of the patient's medical record showed that the patient was evaluated and treated, but was discharged against medical advice. Similar findings were noted in Patient #s 15 and 18 whose disposition in the medical record does not match the disposition recorded in the ED log. During interview with Staff U, Corporate Patient Service Director on 1/19/18 at approximately 10:00 AM, she acknowledged findings.

Based on document review and interview, in one (1) of 12 Emergency Department (ED) records reviewed, the facility failed to provide a medical screening examination to a patient who presented to the ED with suicidal ideation (Patient #2). This failure may result in an emergency medical condition not being identified and treated. Findings include: Review of document titled "Register emergency room Patient" noted: Patient #2, a 39-year-old, presented to the facility's ED 10/01/17 04:06 PM with a complaint of suicidal ideation. Patient stated she has a plan to cut herself, but came to ED instead. The patient was assigned a Triage Category: Level 2 (High risk/needs rapid intervention or sight is threatened) and was taken to the ED Treatment Area. There was no evidence that Patient #2 was subsequently triaged and received a medical screening examination after patient was brought to the treatment area on 10/1/2017 at 4:06 PM. During interview with Staff V, Triage Nurse on 1/23/2018 at approximately 2:00 PM, Staff stated the information listed on the "Register emergency room Patient" document, is from the Quick Registration (QER). She stated Intake nurse (Registered Nurse) as the first point of contact for all patients entering the Emergency Department. The Intake nurse gathers the name, chief complaint, travel history, selects disposition (wait in room or treatment area) and designates a triage classification based on the presenting complaint of the patient. The patient later undergoes a comprehensive triage in order of priority. During interview with Staff U, Corporate Patient Service Director on 1/23/2018 at approximately 2:45 PM, she reported that the facility was not able to locate the electronic record for the patient's encounter on 10/1/2017. She explained that a medical record is created after a comprehensive triage assessment is completed and that Patient #2 was not further assessed. Staff U acknowledged there was no documentation of a comprehensive triage assessment or medical screening evaluation after the patient was seen by the Intake nurse on 10/01/17 at 04:06 PM.

Based on medical record review, document review and interview, in three (3) of 23 patient records reviewed, it was determined the facility failed to ensure that patients presenting to the Emergency Department (ED) receive timely nursing assessment and timely medical evaluation, consistent with the facility's policies and procedures and acceptable standard of practice. These failures may have placed patients at risk for delayed recognition and treatment of their medical condition, with adverse outcomes. Findings include: See: Tag A 1104

Based on medical record review, document review and staff interview, it was determined the facility did not ensure that each patient presenting to the Emergency Department (ED) received a timely medical evaluation and treatment, in accordance with facility's ED policy and procedure. This finding was noted in three (3) of 23 medical records reviewed. (Patient #1, Patient #2, and Patient #3). Findings include: Review of the medical record for Patient #1, identified: This [AGE]-year-old male was triaged in the ED on 1/12/16 at 3:31 PM for complaints of status post fall on 1/10/16, and a left flank pain. Vital signs were as follows: Blood Pressure 90/60; Heart Rate 60; Respiratory Rate 16; Saturation 96% on Room Air: patient rated pain at "0" on a numeric pain scale of "1" to "10". The patient was assigned an Emergency Severity Index (ESI) of Level 3. (Level 3 are patients with significant medical problems requiring multiple resources). The record revealed a late note written by Physician Assistant (PA), on 1/12/16 at 9:31 PM (after patient expired). The PA Note documented his patient evaluation at 8:30 PM. The note stated; during his evaluation of Patient #1 at 8:30 PM, he complained of nausea, vomiting, and lower abdominal pain since last night, denied fever, and chills. The patient was sitting up in bed with vomitus, and while talking to the patient, he became dyspneic, then lethargic, and apneic. A code was called at 9:00 PM; the code was unsuccessful and patient pronounced dead at 9:24 PM. This patient was triaged by Staff A on 1/12/16 at 3:31 PM, and there is no documented evidence that Patient #1 received a nursing reassessment by Staff B, after she was given a hand- off report by Staff A. During interview with Staff F, ED Nurse Manager, on 2/17/16 at 2:00 PM, she stated that there is an expectation that when the Primary Nurse receives a "Hand-Off" report from the Triage Nurse, the Primary Nurse should conduct a nursing assessment of the patient and document the assessment in the electronic medical record. On 1/12/16 at 5:27 PM, approximately two (2) hours after triage, Staff A noted: "The patient is alert and oriented x3, skin cool and moist, ordered EKG (ED Standard order set) and placed on cardiac monitor with sinus rhythm. Patient denies chest pain and dizziness at this time. Vital signs: Blood Pressure 102/70; Heart Rate 66; Respirations 16; and Oxygen saturation 95%." The EKG result dated 1/12/16 at 6:42 PM identified: Ventricular Rate 90; Normal Sinus Rhythm; Possible Left Atrial Enlargement. There is no documented evidence that Patient #1 received a medical evaluation by the ED Attending Physician, who read and signed off on the patient's EKG (time of review of the EKG was not documented), and there is no documented communication between the ED Attending Physician and the Physician Assistant, who were responsible for the care and management of Patient #1. During interview with Staff A (Triage Nurse) on 2/17/16 at 1:00 PM, staff stated that a "Nurse to Nurse Hand-Off report was given to the Primary Nurse (Staff B). She stated that when she observed the patient to be cold and sweating, she ordered EKG and Cardiopulmonary monitor for the patient and notified the Primary Nurse and Charge Nurse of the patient's change in condition. Although the attending physician read and signed off on the EKG, there was no documented evidence that the patient received a medical evaluation until 8:30 PM, approximately five (5) hours after triage and three (3) hours after Staff A observed "skin cool and moist." During the medical evaluation, the patient had a cardiopulmonary arrest and expired at 9:24 PM. During interview with Staff C, ED Site Director, on 2/18/16 at 9:00 AM, the staff stated the PA assigned to the patient had not read the Status Board and was not aware that Patient #1 was his patient, and went off duty. The incoming PA evaluated the patient at 8:30 PM. Staff C was asked what would be the expectation for the care of a patient who is diaphoretic. Staff C stated, "It would have been preferable if the patient was seen by the provider, and the EKG result should have been brought to the attention of the PA responsible for the care of the patient." Staff A and Staff B did not report significant changes in the patient's medical condition to the provider responsible for the care of the patient, in accordance with the facility policy titled, "Triage and Primary Nursing of Adult and Pediatric Patients in the Emergency Department," last revised 5/2014. This policy notes the following: Primary Nurse responsibility includes direct nursing care and decision-making, communication with patients, families, and members of the health care team, documentation and teaching; Once the triage process has been completed, a nurse to nurse hand-off will be completed ... Reassessment includes a full set of vital signs, a focused assessment based on the chief complaint and pain re-assessment." The policy prescribed reassessment of patient at a minimum of every four hours for ESI Levels 3, 4, and 5. Review of the medical record for Patient #2, identified: Patient was triaged in the ED on 12/14/15 at 4:57 PM, with a chief complaint of suprapubic pain for the past three days, associated with one episode of vomiting on 12/13/15. The triage nurse noted stable vital signs, and assigned the patient an Emergency Severity Level (ESI) Level of 3. A Nurse Practitioner (NP) on 12/14/15 at 5:18 PM, noted the patient complained of abdominal pain associated with nausea and dysuria. The NP documented at 5:17 PM an order for "urinalysis and Dipstick with microscopic exam on positive." On 12/14/15 at 11:55 PM, approximately seven hours after arrival of the patient to the Emergency Department, nurse noted, "Patient called, no response/not in area." The final disposition of the patient on 12/15/15 at 00:29 AM noted, "walked out after medical evaluation." The NP orders for urinalysis and Dipstick with microscopic exam for a positive result were not implemented. There was no medical evaluation of the patient prior to the time she was noted to have walked out on 12/14/15 at 11:55 PM. There was no evidence of a nursing assessment after the triage evaluation of the patient at 4:57 PM, in accordance with facility's policy titled, "Triage and Primary Nursing of Adult and Pediatric Patients in the Emergency Department." At interview with Staff C on 2/17/16 at 2:30 PM, Staff C acknowledged that Patient #2 did not receive a medical evaluation before her departure from the ED and the order by the NP for urinalysis and Dipstick were not implemented. Review of the medical record for Patient #3, identified this patient was initially evaluated in the ED on 12/14/15 at 01:58 AM, with complaint of vaginal and suprapubic pain. Triage assessment revealed low-level pain, rated at 2 on a numeric pain scale of 1 to 10. The patient was discharged home at approximately 5:33 AM, after physician assessment and the provision of follow up care instructions. Patient #3 returned to the ED on 12/14/15 at 4:52 PM, with the same complaint of suprapubic pain, but now rated pain at 9. Triage nurse noted the patient was tachycardic (rapid heart beats greater than 100 beats per minute) at 104 beats per minute. The patient was assigned an ESI Level of 3. ED mid level provider on 12/14/15 at 5:12 PM, documented that the patient was in the ED earlier for the same complaint and was awaiting further evaluation by ED physician. On 12/14/15 at 11:55 PM, nurse noted, "Patient called, no response/not in area." There was no documented nursing evaluation of Patient #3, after she was triaged on 12/14/15 at 4:52 PM. The ED mid level provider's assessment at 5:12 PM did not include a medical evaluation and the patient's severe suprapubic pain was not evaluated and managed. The patient presented to the ED at 4:52 PM with severe pain rated at 9 and rapid heart rate (104 beats per minute). No further assessment of the patient is documented until at 11:55 PM when the nurse noted, "Patient called, no response/not in area." This patient left the ED approximately seven (7) hours after arrival with no evaluation or treatment for the pain. At interview with Staff C, ED Site Director, on 2/17/16 at approximately 2:40 PM, she stated there was no nursing assessment of Patient #3, and she confirmed that a medical evaluation was not conducted.