Based on medical record (MR) review, document review and interview, in 1 of 14 MRs, nursing staff failed to obtain Patient #1's blood pressure (B/P) during triage and in 5 of 14 MRs nursing staff failed to reassess Patients (#1 - #5) while in the waiting room or treatment room. This may lead to untoward patient outcomes. Findings include: -- Review of Patient #1's MR (Urgent Care documentation) revealed, on 2/20/17 at 7:27 pm, Patient #1 presented to Urgent Care for treatment, staff reported vomiting, diarrhea and seizure activity. After the patient vomited in the waiting area there was a strong smell of feces. Patient appeared to be in pain (note was entered by the receptionist). Documentation by the Physician's Assistant at 7:56 pm stated "to ED for further evaluation." -- Review of Patient #1's MR revealed, on 2/20/17 at 7:31 pm, Patient #1 presented to the ED with chief complaint of vomiting brown emesis and not being himself. Past medical history included encephalitis, seizures, profound mental retardation, gastroesophageal reflux disease (GERD), erosive esophagitis with gastrointestinal (GI) bleed. Patient #1 was triaged at 7:42 pm as a Level 3. (Acuity level of 1 - 5 with 1 - resuscitation, 2 - emergent, 3 - urgent, 4 - semi-urgent, 5 - non-urgent). No B/P was documented during triage. -- Review of the hospital's policy and procedure (P&P) titled "Triage Patient Flow," last reviewed 4/2017, indicated the triage nurse will document the focused triage assessment, vital signs, chief complaint and assign an acuity level of 1 - 5. Patient #1 was returned to the waiting room until 9:45 pm. (No vital signs or reassessment of Patient #1 was completed while he was in the waiting room.) -- Review of the hospital's P&P titled "Vital Signs Protocol for Emergency Patients," last reviewed 4/2017 indicated that nursing staff should obtain vital signs hourly on patients receiving active treatment and patients in the waiting room not yet evaluated by a provider with an Emergency Severity Index (ESI) triage level of less than or equal to 3 (urgent). Patient #1 was placed in a treatment room at 9:45 pm, 2 hours after triage. He appeared uncomfortable and distressed. He was alert, respirations unlabored, abdomen distended soft and non-tender. Vomit is brown and smells of feces. (No vital signs obtained at this time.) Patient #1 was evaluated by Staff D (ED physician) at 10:11 pm. Physical exam indicated patient was pale, in obvious discomfort,with fecal smelling coffee-ground emesis on the pillow. He was tachycardic (heart rate greater than 100 beats per minute [normal heart rate 60-100]) with regular rhythm. Abdomen was distended and tender. Documentation by Staff D at 10:36 pm indicated the nurse and Staff D were called into Patient #1's room. Patient #1 profusely vomited dark foul-smelling emesis all over room and went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed for over 10 - 12 minutes. Patient expired. -- During interview of Staff D on 12/6/17 at 4:45 pm, he/she indicated Patient #1 was placed in a treatment room and nursing staff did not alert him/her to see the patient right away. Staff D was seeing other patients and indicated the ED was very busy. When he/she went to evaluate Patient #1, he appeared very ill, extremely pale and was moaning and groaning. He/she immediately went out of the exam room to enter orders for laboratory studies and intravenous fluids. Within a few minutes the patient went into cardiopulmonary arrest. CPR was initiated, however, Patient #1 expired. -- During interview of Staff A (Physician) on 12/7/17 at 10:00 am, he/she confirmed the above findings and indicated Patient #1 was triaged as a level 3 without documentation of a B/P. He/she indicated that a triage level can not be determined without obtaining a blood pressure on a patient. -- The same lack of documentation of hourly vital signs of patients in waiting room or treament room was noted for Patients #2, #3, #4, and #5.

Based on findings from interview and document review, the facility did not ensure that all individuals presenting to the Emergency Department (ED) or other areas (obstetrical (OB) unit) are entered into a central log. The lack of a central log in the OB unit does not ensure care provided to these individuals can be tracked. Findings include: -- Per interview of Staff C, ED Nurse Manager on 10/18/16 at 10:50 am, patients presenting to the ED, who are 20 weeks gestation or greater, are triaged by a registered nurse (RN) and if stable are directed to the OB unit for a medical screening exam (MSE). The triage nurse completes the form titled "OB Patient Triage Record" and faxes it to the OB unit. These patients are not entered into the ED Central Log. -- Per interview of Staff H, Charge Nurse OB unit on 10/18/16 at 1:30 pm, patients presenting to the ED who are greater than 20 weeks gestation are transported to the OB Unit for a MSE. The OB unit does not maintain a central log of OB patients transported from the ED for MSE. -- Review of facilities policies and procedures (P&P) did not provide evidence that the facilty had established P&P on a process for OB unit staff to maintain a central log of these patients. -- During interview with Staff A, Director of Quality/Case Management on 10/18/16 at 1:45 pm, he/she acknowledged the above findings.

Based on findings from observation, interview and document review, the facility did not have an adequate process to facilitate patient triage in the Emergency Department (ED). This could lead to potential patient harm. Findings include: -- During tour of the ED on 10/18/19 at 9:55 am, multiple patients were observed standing in one line waiting to be registered at one of three registration stations. Registration included registering for lab work, imaging studies, ambulatory surgery check-in, cardiology visits and emergency room visits. Signage indicated "Registration" above the three registration stations. There was no signage indicating or directing patients to ED registration. -- Per interview of Staff D, Registration Clerk on 10/18/16 at 10:00 am, he/she asks a patient if they are here for an emergency room visit or surgical visit at the time of registration. He/she completes a "short form" registration for emergency room patients and notifies the ED nurse via computer. The patient is then directed to the waiting room. -- During interview of Staff F, ED Charge Nurse on 10/18/16 at 11:45 am, he/she explained that if a patient presents to registration with chest pain, shortness of breath or stroke symptoms, the registration clerk calls into the ED. -- During interview of Staff E, Patient Access Director on 10/18/16 at 10:15 am, he/she indicated that patients presenting for ED services, surgical visits, imaging studies, cardiology visits and lab work register at one of the three registration stations. The ED does not have a dedicated registration clerk. -- Review of a Registration log dated 10/19/16 revealed the following: 7:00 am-11:00 am -15 patients registered for ED services -66 patients registered for laboratory and/or imaging services -4 patients registered for same day surgery All these patients waited in the same registration line. -- Per interview of Staff C, ED Nurse Manager on 10/19/16 at 9:00 am, there is poor signage in the ED waiting area to direct ED patients. There have been discussions with Administration for options to decrease the traffic congestion at registration, e.g., a separate waiting area for ED patients and limiting the number of outpatient labs drawn at the hospital, however, nothing has been implemented. -- Review of the facility's Department of Emergency Medicine meeting minutes, dated 7/14/15, revealed renovations in the ED and lobby would begin October/November 2015. However, meeting minutes dated 10/13/15, revealed renovations to the lobby/registration/ED had been put on hold. Meeting minutes dated 4/12/16, revealed the plan to expand the triage area would be re-addressed. -- During interview of Staff A, Director of Quality/Case Management on 10/19/16 at 5:00 pm, he/she acknowledged the above findings.

Based on findings from medical record (MR) review, document review, and interview, the facility did not ensure that all patients received care according to its policies and procedures (P&P) and current standards of practice. Specifically, 2 of 6 ED MRs (Patients #2, #3) lacked documentation of timely triage and 6 of 6 ED MRs (Patients #2, #3, #4, #5, #6 and #7) lacked documentation of reassessment or monitoring while in the waiting room. Findings include: -- Per review of Patient #2's MR, he (MDS) dated [DATE] at 1:28 pm with a chief complaint of cough. Nursing triaged the patient at 2:52 pm, 1 hour and 24 minutes after presentation. -- Per review of Patient #3's MR, she (MDS) dated [DATE] at 1:37 pm with a chief complaint of vaginal bleeding and spotting and was 5-6 weeks pregnant. Nursing triaged the patient at 3:02 pm, 1 hour and 25 minutes after presentation. -- Review of the facility's P&P titled "Triage Patient Flow," last revised 4/2014, it indicated patients in the waiting room are monitored by the triage nurse and vital signs and reassessments will be performed at least hourly, or more frequently at the discretion of the triage nurse. -- Per review of Patient #2's MR, he (MDS) dated [DATE] with a chief complaint of cough. Nursing triaged the patient at 2:52 pm with an acuity of level =3 (Emergency Severity Index (ESI) of 1-5, 1-resuscitation, 2-emergent, 3-urgent, 4-semi-urgent and 5-non-urgent). The next documentation by nursing was at 6:01 pm (3 hours later) indicating Patient #2 had left without being seen (LWBS). -- Per review of Patient #3's MR, she (MDS) dated [DATE] with a chief complaint of vaginal bleeding and spotting and was 5-6 weeks pregnant. Nursing triaged the patient at 3:02 pm with an acuity level =4. The next documentation by nursing was at 6:57 pm (4 hours later) indicating Patient #3 had LWBS. -- Per review of Patient #4's MR, he (MDS) dated [DATE] with a chief complaint of a fever and cough for 2 days. Nursing triaged the patient at 11:09 pm with an acuity level =4. The next documentation by nursing was at 2:45 am (3 1/2 hours later) indicating Patient #4 had LWBS. -- The same lack of reassessment documentation was noted for Patients #5, #6 and #7. -- During interview of Staff A (ED Director) on 10/19/16 at 12:00 pm, he/she acknowledged the above findings.

Based on findings from document review and interview, in 5 of 6 personnel files, the facility did not ensure Emergency Department (ED) staff had required training in accordance with New York State New York Codes, Rules and Regulations, Title 10 (405.19) Findings include: -- Staff C's (ED Medical Director) personnel file (employed since 7/2003) lacked training certificates for advanced cardiac life support (ACLS) and pediatric advance life support (PALS). -- Staff D's (ED physician) personnel file (employed since 9/2014) lacked training certificates for ACLS and PALS. -- Staff E's (registered nurse (RN) - float to ED) personnel file (employed since 6/2006) lacked training certificates for ACLS and PALS. -- Staff F's (RN - ED) personnel file (employed since 8/2015) lacked training certificates for ACLS and PALS. -- Staff G's (respiratory therapist) personnel file (employed since 5/2011) lacked a training certificate for ACLS. Also the respiratory therapy job description dated 4/2016, indicated that respiratory therapy staff provide care to pediatric patients. However, the job description did not require PALS certification. -- During interview with Staff B (Director of Quality/Case Management) on 10/19/16 at 5:00 pm, he/she acknowledged the above findings.