Based on medical record review, review of staffing and census records, facility policy review, and staff interview, the facility failed to follow Emergency Services policies and physician orders. The cumulative effect of these systemic practices had the potential to affect all patients receiving care in the Emergency Department.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed current facility policies related to performing suicide risk assessments and providing constant observation on suicidal patients and failed to follow physicians orders. This affected Patient #19, Patient #21, Patient #3 and Patient #17. A total of 23 records were reviewed. The current census was 535 patients. Findings include: 1. The medical record of Patient #19 was reviewed on 02/01/18. The patient (MDS) dated [DATE] at 5:29 PM with complaints of a psychotic episode 2 weeks prior and a request for a psychiatric evaluation. The medical record lacked documentation a suicidal risk assessment was completed by staff. The facility policy titled Initial Nursing Assessment was reviewed on 02/02/18 at 9:30 AM. According to the policy staff are required to perform suicide assessment within 1 hour after presenting to the Emergency Department. These findings were confirmed with Staff A on 02/01/18 at 11:00 AM. 2. The medical record of Patient #21 was reviewed on 02/01/18. The patient (MDS) dated [DATE] at 11:05 PM with complaints a suicide attempt. The patient reported jumping into a river in an attempt to harm him/herself. The patient had a history of depression. Although a sitter was noted to be at the bedside of the patient at 11:39 PM, the medical record lacked documentation the Patient Observation form was completed by staff. The patient was transferred to the Psychiatric unit at 02:52 AM. The facility policy titled Suicide Precautions on the Non-Psychiatric Patient Care Unit was reviewed on 02/02/18 at 11:15 AM. According to the policy the patient monitor is required to complete a Constant Observation form that documents the patient's behavior every 15 minutes. These findings were confirmed with Staff A on 02/02/18 at 11:30 AM. 3. The medical record of Patient #3 was reviewed on 01/29/18. The patient (MDS) dated [DATE] at 3:11 PM with complaints of a sickle cell crisis. Patient #3 stated: "I hurt all over in all my joints." A nurse determined the patient's acuity was a 2 (Emergent). Orders for labs were placed at 4:21 PM. The medical record lacked documentation the ordered labs were completed. The Patient Care Timeline revealed the patient was called from the waiting room for a ED room at 8:19 PM and it was discovered the patient had left without being seen. Staff B confirmed these findings on 02/02/18 at 11:35 AM. 4. The medical record of Patient #17 was reviewed on 02/01/18. The patient (MDS) dated [DATE] at 7:05 PM with complaints of chest pain and anxiety. During Triage 1 at 7:07 PM the nurse determined the patient's acuity to be a level 3 (Urgent) using Emergency Severity Index (a five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from the least to most urgent based on acuity and resource needs. 1-resuscitation, 2- emergent, 3-urgent, 4-less urgent, 5-nonurgent). Review of the ED record lacked evidence for the delay in vital signs and EKG for Patient #17 with reported chest pain. The record revealed Triage 1 was completed at 7:07 PM and EKG ordered at 7:51 PM. An ED note by nurse documented at 7:53 PM, patient previously checked. Brought back to Triage room 2 for EKG and vitals by tech. Tech alerted this RN of abnormal EKG. Patient immediately transported to the shock resuscitation unit (SRU). The ED record lacked vital signs until 8:04 PM at which time the patient's heart rate was 147 beats per minute and his/her blood pressure was 127/99. Per the ED Arrival process and Triage workflow policy number UCMC- CEC-SOP-006-02 policy the ED nurse performs Triage1 and tells the patient to have a seat in the lobby or sends them directly to the second triage. Staff B confirmed these findings on 02/02/18 at 11:35 AM.