Based on document review, medical record (MR) review and interview, emergency department (ED) staff did not ensure that emergency care was provided in accordance with generally accepted standards. Specifically, in 4 of 12 MRs reviewed, nursing staff did not obtain vital signs at frequencies required per ED policy and procedure (P&P). In 1 of 12 MRs reviewed, nursing staff did not document complete vital signs for a patient presenting with a mental health condition. This could cause staff to be unaware of a patient's declining condition. Findings include: -- Review of the facility P&P titled "Vital Signs," last reviewed 2/2017, indicated all patients should have a complete set of vital signs done and recorded that includes blood pressure (B/P), pulse (P), respirations (R) and pain level based on an assigned Emergency Severity Index (ESI) triage category. ESI levels include: #1- resuscitation, #2- emergent with abnormal vital signs, #3- urgent, #4- non-urgent and 5- referred. For example, an ESI of #2 with abnormal vital signs require staff to complete vitals signs every 30 minutes for one hour and then if stable, every 30 minutes for one hour, then every 1 hour x 2 followed by every 4 hours until an admission bed is available. -- Review of Patient #1's MR revealed he presented to the ED via emergency medical services (EMS) from urgent care on 8/30/18 at 1:32 pm with chest pain and difficulty breathing. Staff triaged the patient at 1:49 pm and assigned an ESI level of #2. Patient #1's vital signs were abnormal: temperature (T)- 97.6 degrees Fahrenheit (F), P-91, B/P 117/84, R- 20 and 94% oxygen saturation on 4 liters of oxygen. Staff obtained vital signs again at 2:44 pm and B/P was 94/66 (abnormal). An additional set of vital signs were not obtained again until 4:10 pm (one hour and 25 minutes later). At that time B/P was 78/48 (abnormal). There was no documentation that vital signs were completed as required per P&P. -- Review of Patient #2's MR revealed he (MDS) dated [DATE] at 2:52 pm with difficulty breathing. Staff triaged the patient at 3:46 pm and assigned an ESI level of #2. Vital signs were obtained and revealed a B/P of 143/88 (abnormal). Patient #2's vital signs were not obtained again until 6:37 pm (3 hours later). B/P at that time was 167/70. There was no documentation that vital signs were completed as required per P&P. -- Review of Patient #3's MR revealed she (MDS) dated [DATE] at 9:01 pm with chest pain. Staff triaged the patient at 9:05 pm and assigned an ESI level of #2. Vital signs at that time were: B/P- 190/108 and P-134. Patient #3 remained in the ED and staff obtained vitals signs at 9:20 pm: BP-107/69 and P-109 and at 11:15 pm (approximately 2 hours later) BP-115/64 and P-90. There was no documentation that vitals were completed as required per policy. -- Review of Patient #4's MR revealed she presented to the ED at 4:48 am, as a §9.41 Mental Health Law (MHL) emergency admission with local police. Staff triaged Patient #4 and assigned an ESI level #2. Staff obtained vital signs at 4:50 am, 5:12 am, 5:30 am, and 6:05 am. However, there was no documentation that staff obtained vital signs from 6:05 am until patient discharge from the ED at 1:30 pm (over 7 hours later). Additionally, vital signs obtained earlier were not complete, e.g., vital signs at 5:12 am did not include a temperature or respiration and vital signs at 6:05 am did not include a temperature and blood pressure. Each set of vital signs documented was not complete (i.e., T, P, R, B/P and oxygen saturation). -- During interview of Staff A, Director of the ED on 10/16/18 at 12:30 pm, he/she indicated that a complete set of vital signs should include the temperature and oxygen saturation, however this is not included in their P&P. Staff A acknowledged the lack of acceptable frequency of vital signs in the MRs noted above and stated the vital sign P&P is due for revision.

Based on findings from document review and interview, 1 of 3 personnel files reviewed for nursing staff, Staff B, Registered Nurse (RN) lacked documentation of annual mandatory training (e.g., patient's rights, parents bill of rights, advance directives, infection control, fire safety). Findings include: -- Per review of personnel file for Staff B, employed since 7/2012, it lacked documentation of completion of the 2018 annual mandatory training. -- During interview of Staff C, Director of Employee Relations on 10/17/18 at 2:30 pm, he/she stated that all staff are provided their annual mandatory education in May for completion. -- During interview of Staff A, Director of Emergency Department on 10/16/18 at 2:30 pm, he/she stated that Staff B indicated the annual mandatory training was completed. However, there was no documentation of the completed training available to review.

Based on findings from medical record (MR) review, document review and interview, in 1 (Patient #1) of 3 MRs reviewed, the facilty did not effectively integrate coordination and communication between the Emergency Department (ED) and another hospital service (security) to protect the health and safety of a patient. As a result, a patient (Patient #1) eloped from the facility and there was potential of a compromise in his safety. Additionally, an incident report was not completed for this elopement per the facility's policy and procedure (P&P). Findings include: 1. Review of Patient #1's MR identified the following information: Patient #1, a 15 year old, was brought to the ED on 7/14/16 at 11:44 pm with alcohol intoxication and substance abuse. He was triaged at 11:46 pm as a level 2 acuity out of 5, with 1 being life-threatening. A medical screening exam performed at 11:50 pm determined that the patient drank a large amount of vodka and reportedly smoked 4 grams of synthetic marijuana with a noted clinical impression of alcohol intoxication. Patient #1 admitted to thoughts of self harm. A Pediatric PHQ 9-Suicide screen revealed that Patient #1 was not at risk for suicide. An Elopement Risk Assessment revealed that Patient #1 was an elopement risk and considered to be a danger to self or others. Patient #1 was placed in room #14 closest to the nurse's station for maximum visibility. Review of security "Shift Activity Report," dated 7/15/16, revealed at 12:00 am a security guard was monitoring 3 rooms in the ED, including Patient #1 in room #14. The next entry, at 12:00 am, indicated "room #14 walk out." On 7/15/16 at 12:32 am, nursing documentation revealed patient not in room, patient seen leaving by family of next room out ambulance doors. A Request for Law Enforcement Pick-up form dated 7/15/16 was initiated. During interview of Staff B, the Director of Quality and Safety on 7/28/16 at 12:30 pm, he/she acknowledged the lack of communication between the security guard and ED staff. 2. Review of a security "Shift Activity Report," dated 7/15/16 revealed the following information: Any of the following items checked yes MUST be followed by an Incident Report: 1. Missing or Defective Equipment 2. Security Breaches 3. Safety hazards 4. Suspicious Activity 5. Client Policy Violations 6. Injuries/Illnesses 7. Property Damage All the above boxes (1-7) were checked "no". However, during this shift a [AGE]-year-old patient at risk for elopement, did elope and was returned to the hospital by law enforcement. During interview of Staff C, the Facilities Director, on 7/28/16 at 12:00 pm, he/she indicated he/she supervises contracted security staff at the facility. He/she did not know if a patient elopement would constitute a security breach and therefore require an incident report. The facility's policy and procedure (P&P) titled "Incident/Event Reporting," dated 10/28/15, indicated that a close call is an event that could have resulted in patient harm. During interview with Staff B, on 7/28/16 at 12:30 pm, he/she acknowledged that an incident report should have been completed for this elopement.