. Based on record review and interview, the facility did not ensure timely triage of walk-in Emergency Department (ED) patients after check-in, for five (5) of ten (10) ED Medical Records reviewed, nor did they establish a mechanism to address these delays. These delays place patients at risk for deterioration in their condition prior to triage or receiving a medical evaluation. Findings: Review of the Medical Record for Patient #17 documented that the patient (MDS) dated [DATE] at 11:31AM with a complaint of a Urinary Tract Infection. Triage was documented at 12:26PM, fifty-five (55) minutes later as an ESI (Emergency Severity Index) Level 3 (three). Review of the Medical Record for Patient #12 documents that the patient (MDS) dated [DATE] at 12:12PM with complaints of throat and left shoulder pain. Triage was documented at 1:02PM, fifty (50) minutes later as an ESI Level 4 (four). Review of the Medical Record for Patient #16 documents that the patient (MDS) dated [DATE] at 11:47AM with a complaint of left eye pain. Triage was documented at 1:10PM, one (1) hour and twenty-three (23) minutes later as an ESI Level 4 (four). Review of the Medical Records for Patient #13 and Patient #18 documented similar delays of approximately twenty-five (25) to thirty (30) minutes. The facility's Policy and Procedure titled "ED Registration Process" last revised 06/27/14 states the following: When a patient presents to the ED as a walk in he/she will check in with the Registrar utilizing the patient's name and date of birth. The Registrar will complete the check in process, obtain the patient's complaint and place the patient in the Waiting (Reception) Area. The patient will be triaged and the acuity of the patient will be determined. The facility's Policy and Procedure titled " Triage Process in the ED" last revised 06/25/14 states that "Every patient who arrives at the ED either by ambulation, wheel chair or ambulance will be directed to the Triage RN (Registered Nurse), who will complete the Electronic Triage Form and designate an ESI Level for the patient. The Triage RN will then either direct the patient to an assigned stretcher in the Clinical Area or to a seat in the Reception Area but the Policy does not include a process to follow when multiple patients present simultaneously and are waiting to be triaged. The facility's "Principles of Triage and ESI 5 Level Triage System" course materials dated 2016 document that the Triage Nurse assigns an ESI (Emergency Severity Index) Level to each patient. The determination of Levels 3 and 4 is based on the number of resources (i.e. Laboratory, Radiology) and does not require immediate intervention. The course documents that the Triage Nurse is responsible to monitor the Waiting Room, and when multiple patients present to triage, to prioritize according to stated complaint and general appearance (of the patient). The course material also states "Call for help PRN (as needed)", but does not include specific guidelines. Per interview with Staff I, Nurse Manager of Clinical Operations for the ED, on 07/21/16 at 10:00AM, the Flow Coordinator RN will monitor the Tracking Board, open another Triage Room and send an additional RN to triage patients, but they are not tracking or reporting on the check-in to triage times. Per interview with Staff L, ED Medical Director, on 07/21/16 at 11:30AM, they are not currently collecting data or reporting on the time between check-in and triage. .

. Based on interview and document review, the Medical Staff did not establish criteria delineating the qualifications that an Emergency Department Physician must possess in order to supervise the provision of Emergency Care Services. This failure may lead to a non-qualified Physician supervising the provision of Emergency Care Services. Findings: The facility's current Medical Staff Bylaws did not contain established criteria including the necessary education, experience or specialized training, delineating the qualifications that a Medical Staff Member must possess in order to provide supervision of Emergency Care Services. The facility's Emergency Department: Plan for Providing Care / Services dated July 2015, states "The Emergency Department Physician staffing is the responsibility of the Chairmen" but lacked any information regarding designation of a Charge Physician or the qualifications required for this designation. During an interview on 07/21/16 at 11:30AM, Staff L, ED Medical Director, stated that "The Team Two Doctor is designated as the Charge Physician for the Unit". When asked if there were specific criteria delineating the qualifications the Physician must possess in order to supervise Emergency Care Services, he responded that to his knowledge "There is no written criteria for designating the role of the Charge Emergency Physician". This was confirmed during an interview in the afternoon by Staff D, Senior Vice President of Administration.