Based on document review, observation, and interview, in 1 (one) of three (3) emergency code carts inspected, the facility did not implement its policy to ensure that pediatric emergency cart was equipped with a pediatric bag-valve-mask required for emergency ventilation. The failure to have a pediatric bag-valve-mask readily available for use during emergencies may place patient at risk for harm. Findings include: During inspection of the Pediatric Emergency Code Cart on 11/15/16 at approximately 12:00 PM, the cart did not contain a Pediatric bag-valve-mask. Review of the facility policy titled "Code Cart - Broselow Pediatric Emergency," last revised August 2015, stated that a Pediatric bag-valve-mask is to be placed on the outside of a Pediatric code cart. During interview with Staff E, Registered Nurse on 11/15/2016 at 1:09 PM, staff stated that she checked the Pediatric Code Cart in the morning of 11/15/16 and confirmed that she did not observe that the Pediatric bag-valve-mask was missing from the cart. When Staff D, Clinical Nurse Manager was advised to call for immediate delivery of the device to the unit, it took approximately 5 minutes for the bag valve device to be delivered. This finding was confirmed with Staff D and Staff A, Assistant Vice President, who were present during the inspection.

Based on medical record review, document review, and interview, staff failed to assess a patient to determine if an Emergency Medical Condition (EMC) exists upon the arrival of the patient to the Emergency Department (ED). This finding was noted in 1 (one) of 22 medical records reviewed (Patient #1). This failure may have placed the patient at risk for harm. Findings include: Review of medical record from Hospital A revealed that Patient #1 (MDS) dated [DATE] at 21:05 and was seen by the "Greeter" in the "PRE ER" area. Her complaint was recorded by the greeter as shortness of breath, vomiting, and arm pain. Review of the ED Log noted that Patient #1 arrived on 10/21/16 at 21:05 and departed the ED on 10/21/16 at 21:47. There was no documentation in the ED log of the patient's complaint; priority level; the assignment of an ED Physician; and the disposition of the patient. During interview with Staff G, Triage Nurse, on 11/16/16 at about 11:00 AM and witnessed by Staff A, Assistant Vice President, and Staff C, Director of Nursing ED, Staff G stated the following: "The patient came with her son. The son is personally known to me. We grew up together. When I called the patient for triage twice, I could not find her but I recognized the last name as belonging to the son so I looked down the hallway for him. He was standing by the doorway of the toilet. I asked him for the patient and he said his mother was in the bathroom and that she has diarrhea. I informed him that I would call another patient meanwhile. The patient's son stated that his mother was very weak and he requested for a wheelchair or stretcher for her. I told him there were no wheelchairs or stretchers. He asked me when I think his mother would be seen and placed in a bed and I told him that all the beds were taken. I told him that there were 45 patients being treated in the back and there are no beds. The son said you must be crazy busy today and I said yes. He stated that his mother's doctors were all connected to another hospital and he asked if I would advise him to take her there. I said I could not advise him to take her there. I left the son and I called the next patient. I did not see the mother during my discussion with the son but I saw the son walk out of the ED with the mother later". The facility Policy and procedure titled "Emergency Severity Index (ESI) and Rapid Triage", effective April 2015, stated the following: "A Registered Professional Nurse is assigned to triage... the Triage Nurse will assess patients for priority of care as they arrive into the Emergency Department and assign them to the appropriate area". The triage nurse did not assess the patient upon arrival to the Emergency Department to determine the patient's acuity and medical priority for a medical screening evaluation. The facility triage policy did not include the process of a "greeter" interaction with patients upon their arrival to the ED. Review of medical record from Hospital B revealed Patient #1 arrived at the facility on 10/21/16 at 2158 and triaged at 2201 with complaints of nausea, vomiting, and diarrhea. The triage assessment noted the patient was lethargic and hypotensive. Vital signs at triage were as follows: Temperature - 97.5 Fahrenheit; Pulse - 65/minute; Respirations - 20/minute; Blood Pressure - 79/42; and Pulse Oximetry (Oxygen saturation) - 95 %. The patient was evaluated by the ED physician with a clinical impression of sepsis requiring inpatient admission and management in the Critical Care Unit.

Based on document review and interview, the facility did not ensure that the Emergency Department (ED) log is complete. This finding is evident in five (5) of 22 medical records reviewed (Patient #s 1, 19, 20, 21 & 22). Findings include: Review of the ED Log noted that Patient #1 arrived on 10/21/16 at 21:05 and departed the ED on 10/21/16 at 21:47. There was no documentation in the ED log of the patient's complaint, priority level, the assignment of an ED Physician, and the disposition of the patient. Similar findings regarding lack of documentation in the ED log of patients' complaint, priority level, the assignment of an ED physician, and disposition were noted for Patient #s 19, 20, 21, & 22. At interview with Staff A on 11/16/16 at approximately 12:15 PM, the staff acknowledged the gaps in the emergency room log.