. Based on record review, Policy review and interview, the facility failed to establish a follow-up procedure for triaged patients that left without being seen by a Physician in five (5) out of nineteen (19) ED (Emergency Department) Records reviewed (Patients #14, #15, #24, #25 and #26). Findings: Review of the medical record for Patient #26 documents that the patient (MDS) dated [DATE] at 5:12PM with complaint of Abdomen Pain. The initial triage was documented at 5:34PM. The patient was triaged as "Urgent" Level 3. The Medical Record documents discharge at 2:08AM on 12/30/14 as "Not seen by MD/PA (Medical Doctor/Physician Assistant) ". The record lacks documented evidence of follow up with the patient after they left the ED. Review of the medical record for Patient #15 documents that the patient (MDS) dated [DATE] at 11:20AM with complaints of Shortness of Breath with Chest Pain. The initial triage call was documented at 11:33AM. The patient was triaged as "Urgent" Level 3. The Medical Record documents discharge at 6:12PM on 12/29/14 as "Not seen by MD/PA". The record lacks documented evidence of follow up with the patient after they left the ED. Review of the medical record for Patient #25 documents that the patient (MDS) dated [DATE] at 5:03PM with complaint of Abdominal Pain. The initial triage call was documented at 5:05PM. The patient was triaged as "Urgent" Level 3. The Medical Record documents discharge at 11:06PM as "Not seen by MD/PA". The record lacks documented evidence of follow up with the patient after they left the ED. Similar findings were noted in two (2) additional records reviewed (Patients #14 and #24). An interview on 01/06/14 at 11:00AM with Staff Members #8 and #7 confirmed that the facility lacks a procedure for follow up with patients that leave the Emergency Department after triage without being seen by an MD.

. Based on record review and interview, the facility failed to ensure: a) a timely Medical Evaluation for Emergency Department (ED) patients after Triage in five (5) out of nineteen (19) ED Medical Records reviewed (Patients #14, #16, #24, #25 and #26), and b) adequate staffing to provide appropriate Nursing care to meet the needs of admitted patients housed in the emergency room in two (2) out of eight (8) Medical Records (Patients #20 and #21). . Findings: . a) Review of the medical record for patient #26 revealed the patient (MDS) dated [DATE] at 5:12PM with complaints of Abdomen Pain for two (2) weeks stating she had a CT (computed tomography) scan which showed a Gallbladder Polyp and was directed to the ED by her Physician. . The initial triage call was documented at 5:34PM. The patient was triaged as "Urgent" Level 3. . The first follow up triage call was documented on 12/30/14 at 1:36AM, eight (8) hours and two (2) minutes after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD (Physician)/ PA (Physician's Assistant)" at 2:08AM. . The Medical Record lacks documentation that the patient received a Medical Evaluation during the eight (8) hour wait from the initial presentation until the first follow up triage call. . Review of the medical record for patient #14 (MDS) dated [DATE] at 6:46PM with complaints of Fever, Headache, Back and Throat Pain. . The initial triage call was documented at 6:51PM. The patient was triaged as "Urgent" Level 3. . The first follow up triage call was documented on 12/11/14 at 2:06AM, seven (7) hours and fifteen (15) minutes after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD/PA" at 2:58AM. . The Medical Record lacks documentation that the patient received a Medical Evaluation during the seven (7) hour wait from the initial presentation until the first follow up triage call. . Review of the medical record for patient #16 reveals the patient (MDS) dated [DATE] at 6:40PM with complaint of Chest Pain. . The initial triage call was documented at 6:42PM. Nursing Notes at 6:44PM document "appears to be in moderate distress". The patient's Heart Rate was 116, Respiratory Rate 24 and Pain Level 10. The patient was triaged as "Urgent" Level 3. . A Nursing Note at 6:50PM documents "Patient very restless unable to sit still for EKG, reports he can't breathe". An EKG shows the patient in Sinus Tachycardia. No further Nursing Documentation noted in the record. . Documentation notes the patient "departed" and "Not seen by MD/PA" at 10:57PM. . The Medical Record lacks documentation that the patient received a Medical Evaluation during the four (4) hour wait from the initial presentation until discharge. . Review of the medical record for patient #24 reveals the patient (MDS) dated [DATE] at 5:39PM with complaints of Fever, Cough and Pleurisy. The initial triage call was documented at 6:30PM. The patient was triaged as "Urgent" Level 3. . The first follow up triage call was documented on 12/23/14 at 12:31AM, seven (7) hours and eight (8) minutes after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD/PA" at 1:22AM. . The Medical Record lacks documentation that the patient received a Medical Evaluation from a Physician during the seven (7) hour wait from the initial presentation until the first follow up triage call. . Review of the medical record for patient #25 reveals the patient (MDS) dated [DATE] at 5:03PM with complaints of Right Back and Abdomen Pain. The initial triage call was documented at 5:05PM. The patient was triaged as "Urgent" Level 3. . The first follow up triage call was documented at 11:03PM, six (6) hours after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD/PA" at 11:06AM. . The Medical Record lacks documentation that the patient received a Medical Evaluation during the six (6) hour wait from the initial presentation until the first follow up triage call. . b) Review of the medical record for patient #21 reveals the patient (MDS) dated [DATE] at 3:27PM in Respiratory Distress. The patient was triaged as "Emergent" Level 2, admitted as an inpatient at 7:57PM and was housed in the ED until 11:45PM when the patient was transferred to the Medical Intensive Care Unit (MICU). . Review of the Medical Record revealed that an MD Order was placed at 3:52PM, shortly after the patient arrived at the ED for insertion of a Foley catheter and a STAT (immediate) Urinalysis. Documented evidence shows the Foley catheter was not placed until 11:20PM and the Urinalysis was not obtained until 12:30AM on 01/08/15, more than seven (7) hours after the STAT Order was placed. . Review of the ED Staff Schedule documents the Nurse's assignment as having two (2) MICU patients, six (6) ED "Treat & Release" patients and two (2) admitted Med-Surg patients during the 7P-7A shift on 01/07/15. The Nurse was assigned ten (10) patients, including the two (2) admitted Critical Care patients. . Review of the medical record for patient #20 reveals the patient (MDS) dated [DATE] at 10:47PM with complaint of Vomiting Blood. The patient was triaged as "Emergent" Level 2, admitted as an inpatient on 12/12/14 at 2:37AM and was housed in the ED until 13:30PM on 12/13/14 when the patient was transferred to the Intensive Care Unit (ICU). . Review of the Medical Record revealed STAT MD Orders were placed at 11:58PM on 12/11/14, for a STAT Urinalysis. Documented evidence shows the Urinalysis was not obtained until 7:48AM on 12/13/14, more than thirty-one (31) hours after the STAT Order was placed. . Review of ED Staff Schedule documents the Nurse's assignment as having one (1) ICU patient, as well as seven (7) admitted Med-Surg patients throughout the 7P-7A shift on 12/11/14. The Nurse was assigned eight (8) admitted patients, including the Critical Care patient. . On 12/29/14 one (1) Nurse's assignment included fourteen (14) patients, including two (2) MICU patients, four (4) admitted Med-Surg (Medical-Surgical) patients and eight (8) ED "Treat & Release" patients. . On 12/29/14 another Nurse's assignment included six (6) patients, including two (2) MICU patients, four (4) admitted Med-Surg patients, and three (3) ED "Treat & Release" patients. . On 12/16/14 one (1) Nurse's assignment included six (6) patients, including one (1) ICU patient, one (1) admitted Telemetry patient, three (3) admitted Med-Surg patients and two (2) ED "Treat & Release" patients. . These assignments were confirmed during interview with Staff #8 on 01/09/14 at 1:30PM.