. Based on document review, Medical Record review and interview, the Emergency Department (ED) Staff did not ensure that patients assessed with reported pain levels of seven (7) and above, were assigned an Emergency Severity Index (ESI) Level of two (2), as per facility Policy, in three (3) of three (3) Medical Records reviewed. Findings included: The facility Policy and Procedure titled "Triage- Emergency Severity Index (ESI)" last revised on 11/12/2015, directed Nursing Staff to assign an "ESI LEVEL TWO" to patients with a "high risk situation...and/or severe pain (patient rating of greater than or equal to 7 on 0-10 pain scale)." Review of Patient #3's Medical Record identified that this patient (MDS) dated [DATE] at 10:07PM and was triaged at 10:09PM. Pain levels of eight (8) both at rest and with activity were documented. Patient #3 was assigned an ESI level of three (3). The patient was not evaluated by a provider and left the facility without being seen on 10/10/18 at 1:40AM. Review of Patient #11's Medical Record identified that this patient (MDS) dated [DATE] at 5:49PM and was triaged at 5:57PM. The patient had pain levels of eight (8) both at rest and with activity. Patient #11 was assigned an ESI Level of three (3). The patient was not evaluated by a provider and left the facility without being seen on 10/09/18 at 9:44PM. Review of Patient #17's Medical Record identified that this patient (MDS) dated [DATE] at 11:30PM and was triaged at 11:35PM. The patient had a pain level of seven (7) at rest, and a pain level of eight (8) with activity and was assigned an ESI Level of four (4). The patient was not evaluated by a provider and left the facility without being seen on 01/06/18 at 2:13AM. An interview with Staff A (Executive Director of Patient Care Services) on 12/13/18 confirmed the above findings.

. Based on observation, document review, and interview, the Emergency Department (ED) Staff failed to follow the Policies for (A) the secured storage of needles and sharps in Patient Treatment Areas, in five (5) of six (6) observations, and (B) the secure storage of medication received from the Pharmacy, in 1 (one) of 1 (one) observation. This may have placed patients at increased risk for injury or adverse outcomes. * Findings for A: The facility's Policy and Procedure titled "Sharps Safety Devices" last revised 01/16 contained the following statement: "Sharps products, e.g., needles, syringes with needles, are to be locked or maintained in a secured manner, e.g., under staff control, in locked cabinets, drawers." Observations in the facility's Adult ED during a tour between 10:00AM and 11:45AM on 03/06/17 identified the following: At 10:40AM outside Room #8 a suture supply cart containing suture needles, staple removal kits, and a syringe was observed unlocked. At 10:45AM outside Room #13 an IV / Phlebotomy supply cart containing Phlebotomy needles, Angio catheters, and other supplies was observed unlocked. Similar findings were observed for carts located outside Room #16 and outside Room #26. These observations were made in the presence of Staff Members G, R, and A who confirmed the findings. During an interview with Staff G and Staff R at the time of these observations, they acknowledged that the carts should have been locked. During observations of the facility's Pediatric ED on 03/06/17 at 2:00PM, a suture supply cart containing suture needles and supplies was observed unlocked in the "Rapid Access" area. This observation was made in the presence of Staff T and Staff K who confirmed the findings. * Findings for B: The facility's Policy and Procedure titled "Storage and Accessibility of Medication" last revised 02/17 stated the following: "All medications must be stored in an area that can be locked and/or is inaccessible to patients and visitors ... Medications must be placed in approved storage areas upon receipt on nursing units [lockable medication carts/wall cabinets or medication room] ...All medications removed from storage must remain secure at all times and must not be left unattended ..." Observations in the facility's ED on 03/07/17 at 3:10PM identified an unsecured and unattended medication at the Nursing Station. The administration kit for Lupron Depot 11.25mg, contained a pre-filled medication syringe and needle. The medication was labeled with the patient's name, location, and warning label which stated "Caution: Hazardous Drug, observe special handling, administration and disposal requirements." Per interview with Staff F on 03/07/17 at 3:17PM, the medication should not have been left unsecured at the Nursing Station. Staff F stated the expectation is for staff who receive medications [from the Pharmacy] to "hand-deliver" medications to the intended recipients or "secure" medications in their medication storage carts. This was confirmed with Staff R.

. Based on Medical Record review, document review and interview, the Emergency Department (ED) did not ensure that Patient #1 was reassessed as per facility Policy while in the Waiting Area. This potentially places patients at increased risk for delays in the accurate re-assessments of their Emergency Severity Index (ESI) Levels. Findings: Review of Patient #1's Medical Record identified the following information: On 03/28/16, this [AGE]-year-old male was referred to the Emergency Department (ED) from his Primary Care Provider (PCP) for shortness of breath and right shoulder pain. The patient arrived to the ED, denied shortness of breath but complained of ten (10) out of ten (10) shoulder pain on the pain rating scale. He was triaged at 9:47AM as an Emergency Severity Index (ESI) Triage Level 3, and instructed to wait in the Waiting Area. Patient had Vital Signs (VS) re-assessed at 10:47AM and 2:30PM, not every hour as per facility Policy, and pain score was not reassessed. After an approximately five and a half (5½) hour wait in the ED Waiting Area, the patient left without being seen (LWBS) by a Physician at 3:10PM. The facility Policy and Procedure (P&P) titled "Triage - Emergency Severity Index (ESI)" dated 12/29/15 stated "...If [Waiting Room] patients have an extended wait time, they will be reassessed at a minimum of every 1 [one] hour. The Triage Nurse is responsible to ensure reassessment of Waiting Room patients and escalation of any change in patient condition." This same facility Policy also states "...A temperature, heart rate, respiratory rate, blood pressure, oxygen saturation level and pain score will be performed on all patients as part of the nursing assessment ... Vital Signs are utilized to determine if a patient's ESI level should be upgraded." During interview with Staff I (ED Triage Nurse) on 06/02/16 at 11:00AM, Staff I demonstrated on the Electronic Medical Record where ED Waiting Room patients' Assessment information is documented and indicated patients are assessed every one (1) hour. When asked what exactly does the Assessment entail, Staff I explained the Assessments included observation of patients and recording of their VS. During interview with Staff E (ED Triage Nurse) on 06/03/16 at 1:30PM, Staff E stated "Reassessments [of the Waiting Room patients] always include taking VS every hour." When asked if patients are just observed or watched for reassessments, Staff E stated "Yes, we are always watching the patients, but this is in addition to the hourly VS Assessments we are doing". This was confirmed with Staff G (Nursing Director of Patient Care Services) and acknowledged by Staff A (Associate Executive Director of Quality Management). .

. Based on documentation review and interview, the Medical Staff did not establish criteria for delineating the qualifications a Medical Staff Member must possess in order to supervise the provision of Emergency Care Services. This failure may lead to non-qualified Medical Staff Members supervising Emergency Care Services. Findings: A review of the Job Description of the emergency room Chair does not include duty of direct supervision of the Emergency Care Services Staff. A review of the facility's Bylaws do not contain specific criteria including the necessary education, experience and training to delineate the qualifications a Medical Staff Member must possess in order to provide supervision of Emergency Care Services. An interview with Staff H, Chair of Emergency Medicine, on 06/03/16 at 10:30AM revealed that in the event of his absence, the Associate Chairperson would be present to oversee staff in the Emergency Department. And in the event that neither of them are available, a member of the Blue Desk Team is in charge. On 06/03/16 at 1:30PM Staff A, Quality Assurance, stated that there is no specific Policy and Procedure that denotes the specific qualifications of a Supervising Physician in order to be granted Privileges for the supervision of Emergency Care Services.