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Based on hospital policy and procedure reviews and staff interviews, the emergency department (ED) nursing staff failed to assess and/or reassess one or more patient vital signs [Blood Pressure (BP), Temperature (T), Pulse (P), Respirations (R), Pulse Oximetry (P/Ox)] per hospital policy for 6 of 8 ED patient records sampled (#20, #5, #6, #3, #7, and #4).

The findings include:

Review of current hospital policy "Assessment of Patients: VITAL SIGNS," reviewed/revised April 2013, revealed "I. POLICY To set a standard for measuring and recording blood pressure, temperature, pulse, respirations, pulse oximetry, weight and height to aid in the diagnosis and treatment of ED patients. ...III. DEFINITION For the purpose of this document includes temperature, pulse, respirations, blood pressure, pulse oximetry. ...VI. INTERVENTIONS All patients presenting to the Emergency Department will have vital signs documented according to the following criteria. A. All patients over the age of three: 1. Blood Pressure a. Vital signs, to include temperature, pulse, respirations, blood pressure and pulse oximetry, ...i. Birth - 3 years - Vital signs not to include blood pressure, unless ESI (emergency severity index) level 1 or 2. Temperature method will be rectal if presenting with complaints of illness. If presenting with complaints of injury the temperature method will be at he discretion of the RN. ...C. Minimum requirements for patients in treatment room or in the waiting room: Level 1: every 5-10 minutes Level 2: every 15 minutes Level 3: every 2 hour Level 4: every 4 hours Level 5: every 4 hours D. For all patients who have received narcotics, antipyretics or blood pressure altering medications vital signs will be reassessed within one hour of intervention. VII. DOCUMENTATION Documentation of Vital Signs: The RN will document in the electronic medical record all vital signs obtained during the patient s length of stay as described above in the priority reassessment times. ..."

Review of current healthcare system policy "ASSESSMENT - REASSESSMENT OF THE EMERGENCY DEPARTMENT PATIENT," written 02/13, revealed "I. POLICY All patients presenting to the Emergency Department will be assessed and categorized using the ESI 5 Level Triage System. The recorded data reflects assessment, planning, implementation and evaluation of the patient from admission through discharge, utilizing the nursing process, which is specific to their age and reason for visit. II. SUMMARY To define the scope and content of screening, assessment, reassessment and documentation guidelines for nursing. To assure that established criteria will be assessed and reassessed on all Emergency Department patients. III. DEFINITIONS Level 1-Resuscitation....Level 2-Emergent....Level 3-Urgent....Level 4 Semi-Urgent....Level 5-Non-Urgent. IV. INTERVENTION A. Screening Assessment ...2. Screening assessment by the RN, as outlined in the documentation tool includes: ...c. Vital signs, to include temperature, pulse, respirations, blood pressure and pulse ox... i. Birth-3 years -Vital signs not to include blood pressure, unless ESI level 1 or 2. Temperature method will be rectal if presenting with complaints of illness. If presenting with complains of injury the temperature method will be at the discretion of the RN. ...C. Reassessment: ...Reassessment of based on the plan of care will be documented at least every four hours, or more frequently with change in condition. Responses to treatment, therapy and diagnostic procedures will be documented. 1. Vital signs will be reassessed every 4 hours or more frequently based on patient condition. a. Exceptions: i. Psychiatric patients' who have been medically cleared, awaiting psychiatric Evaluations and/or placement will be reassessed, including vital signs, at a minimum of every 8 hours. 2. Reassessment of vital signs will be documented within one hour of admission, discharge or transfer. a. Exceptions: i. For ESI levels 4 and 5, vital signs are reassessed within 4 hours of discharge. ii. If length of stay less than 1 hour and initial vital signs within normal limits, vital signs will not be reassessed at discharge. ..."

1. Open ED record review on 09/11/2014 for Patient #20 revealed a 31 year old female presented to the hospital's satellite campus ED on 09/11/2014 at 0137 for psychiatric complaints and was subsequently placed under involuntary commitment. The patient was triaged by a RN at 0149 and assigned an ESI Level 3. Review revealed initial vital signs at 0149 were assessed as T 98.9 degrees F, P 90, BP 142/101, R 18, P/Ox 100% Room Air (RA). Record review revealed the patient's vitals signs were reassessed at 0800 (6 hours 11 minutes later) as T 98.8 F, P 91, R 16, BP 136/93, P/ox 96% RA. Record review revealed the patient was changed to observation status at 0432. Record review failed to reveal any available documentation by nursing staff of vital signs being obtained every 2 hours per policy from 0149 until 0432 (time medically cleared).

Interview with ED Manager #2 revealed the vital signs policy should be followed for psychiatric patients until the patient is considered medically cleared by the ED provider. Interview revealed once medically cleared the vital signs are obtained every 8 hours. Interview revealed Patient #20 was considered medically cleared at 0432 when her status was changed to observation. Interview confirmed the patient was triaged as a ESI level 3 requiring vital sign reassessment every 2 hours. Interview confirmed no available documentation the patient's vital signs were reassessed every 2 hours from 0149 to 0432. Interview confirmed the ED nursing staff failed to follow hospital policy.

2. Closed ED record review on 09/10/2014 for Patient #5 revealed a 7 month old female patient presented to the hospital's main campus ED on 09/07/2014 at 1203 for complaints of fever, cough and nasal drainage. The patient was triaged by a RN at 1231 and assigned an ESI Level 4. Review revealed initial vital signs were assessed at 1231 as T 102.6 degrees F (elevated), P 157, P/Ox 100% RA. Record review revealed the patient was administered Ibuprofen (antipyretic for fever control) 113 milligrams (mg) per physician's order at 1246 by an RN. Record review failed to reveal any available documentation of assessment of the patient's respiration rate at triage or reassessment of the patient's vital signs after Ibuprofen administration and prior to discharge from the ED at 1248. Record review revealed the patient was discharged with a diagnosis of Fever and Upper Respiratory Infection.

Interview on 09/10/2014 at 1115 with ED Manager #1 revealed Patient #5's temperature was considered abnormal. The patient had a "fever." Interview revealed nursing staff should obtain a complete set of vital signs (T, P, R, BP, Pulse/ox) when patients are triaged. Interview revealed a respiration rate is a vital sign. Interview confirmed no available documentation of a respiration rate for Patient #5. Interview confirmed the patient was administered Ibuprofen for fever control at 1246 and discharged at 1248 (2 minutes later). Interview revealed the patient's temperature should have been reassessed because it was abnormal. Interview confirmed no available documentation the patient's vital signs were reassessed after the medication administration and prior to discharge. Interview confirmed the ED nursing staff failed to follow hospital policy.

3. Closed ED record review on 09/10/2014 for Patient #6 revealed a 7 month old female patient presented to the hospital's satellite campus ED on 09/01/2014 at 2107 for complaints of sneezing and nasal congestion. The patient was triaged by a RN at 2123 and assigned an ESI Level 3. Review revealed initial vital signs were assessed at 2123 as T 99.6 degrees F, P 126, R 32, P/Ox 99% RA. Record review revealed the patient's vital signs were reassessed at 2325 as P 143 and Pulse Ox 98% (2 hours 2 minutes later). Record review failed to reveal any available documentation of reassessment of the patient's temperature and respiration rate at the time of discharge. Record review revealed the patient was discharged with a diagnosis of nasal congestion.

Interview on 09/10/2014 at 1305 with ED Manager #2 revealed the vital signs policy should be followed. Interview revealed when vital signs are assessed, all elements (T, P, R, BP, P/Ox) should be assessed and documented. Interview confirmed Patient #6 was triaged as a ESI Level 3 requiring vital signs to be reassessed every 2 hours. Interview confirmed no available documentation by nursing staff of reassessment of respiration rate or temperature at the time of discharge. Interview confirmed the ED nursing staff failed to follow hospital policy.

4. Closed ED record review on 09/10/2014 for Patient #3 revealed a 3 week old female patient presented to the hospital's main campus ED on 02/01/2014 at 0144 for complaints of cough and congestion for one week. The patient was triaged by a RN at 0117 and assigned an ESI Level 4. Review revealed initial vital signs were assessed at 0144 as T 98.4 degrees F, P 138, and R 30. Record review failed to reveal any available documentation of assessment or reassessment of the patient's pulse ox upon triage or prior to discharge from the ED at 0356. Record review revealed the patient was discharged with a diagnosis of cough.

Interview on 09/10/2014 at 1115 with ED Manager #1 revealed nursing staff should obtain a complete set of vital signs (T, P, R, BP, Pulse/ox) when patients are triaged. Interview revealed a pulse ox is a vital sign. Interview confirmed no available documentation of a pulse ox assessed or reassessed for Patient #3 upon triage or prior to discharge. Interview confirmed the ED nursing staff failed to follow hospital policy.

5. Closed ED record review on 09/10/2014 for Patient #7 revealed a 13 month old male patient presented to the hospital's satellite campus ED on 02/01/2014 at 0031 for complaints of cold symptoms, wheezing, and croupy cough. The patient was triaged by a RN at 0039 and assigned an ESI Level 3. Review revealed initial vital signs were assessed at 0039 as T 100.2 degrees F, P 130, R 32, P/Ox 95% RA. Record review revealed the patient was administered Tylenol (antipyretic for fever control) 186 mg per physician's order at 0133 by an RN. Record review failed to reveal any available documentation of reassessment of the patient's vital signs after Tylenol administation at 0133 and prior to discharge at 0147. Record review revealed the patient was discharged with a diagnosis of fever and croup syndrome.

Interview on 09/10/2014 at 1305 with ED Manager #2 revealed the vital signs policy should be followed. Interview revealed when vital signs are assessed, all elements (T, P, R, BP, P/Ox) should be assessed and documented. Interview confirmed Patient #7 was triaged as a ESI Level 3 requiring vital signs to be reassessed every 2 hours. Interview confirmed no available documentation by nursing staff of vital signs reassessed after Tylenol administration and prior to discharge. Interview confirmed the ED nursing staff failed to follow hospital policy.

6. Closed ED record review on 09/10/2014 for Patient #4 revealed a 5 day old female patient presented to the hospital's main campus ED on 01/01/2014 at 2305 for complaints of decreased activity since birth. The patient was triaged by a RN at 2310 and assigned an ESI Level 3. Review revealed initial vital signs were assessed at 2310 as T 98.6 degrees F, P 134, R 28, P/Ox 98% RA. Record review revealed no available documentation that a complete set of vital signs (T, P, R, P/Ox) was obtained every two hours per policy prior to discharge at 0357. Record review revealed the patient was discharged with a diagnosis of well child check.

Interview on 09/10/2014 at 1115 with ED Manager #1 revealed nursing staff should obtain a complete set of vital signs (T, P, R, BP, Pulse/ox) when patients are triaged. Interview confirmed no available documentation of complete sets of vital signs assessed for Patient #4 prior to discharge. Interview confirmed the ED nursing staff failed to follow hospital policy.

Based on policy and procedure reviews, observations during tour and staff interviews, the hospital's Emergency Department (ED) staff failed to maintain emergency supplies and equipment in a manner to ensure an acceptable level of safety and quality by failure to store clean supplies off the floor, perform daily emergency crash cart checks, and discard expired intravenous fluids (IVF) for 2 of 2 Emergency Department campus locations toured.

The findings include:

Review of current hospital policy "MATERIALS MANAGEMENT/STORE ROOM" revised/reviewed 02/2014, revealed "I. PURPOSE To control or minimize the risk for transmission of infections and/or communicable disease to (Hospital name) Materials Management/Storeroom customers, patients, and staff. ...III. PROCEDURE ...B. Storage and Dispensing of Supplies 1. Storage ...b. Patient care items must be stored at least 8" (inches) above the floor... e. Commercial products are checked for expiration dates prior to issuing. ...h. Areas of the hospital in which medical supplies are stored and dispensed are inspected monthly by Storeroom personnel. The areas are monitored for prior storage conditions, including expiration of dated material and cleanliness of the supplies. ..."

Review of current hospital policy "DEFIBRILLATOR AND EMERGENCY CART MAINTENANCE" reviewed/revised 07/13, revealed "I. POLICY The cardiac defibrillator and the emergency cart will be checked at least daily during normal business hours for proper functioning and evidence of appropriate supplies. ...IV: DOCUMENTATION Ensure defibrillator checklist is completed on a daily basis."

1. Observations during tour of the Hospital's main campus emergency department on 09/10/2014 at 1500 revealed Equipment Room #4 used to store clean medical equipment and supplies. Observation revealed the following patient care supplies being stored on the floor underneath the storage shelving units:
01. Three (3) unopened clear plastic specimen containers;
02. One (1) unopened disposable pediatric blood pressure cuff;
03. One (1) unopened disposable oxygen saturation sensor;
04. One (1) unopened injection needle;
05. One (1) unopened syringe with injection needle; and
06. One (1) unopened red port cap.
Continued observations during tour revealed an adult emergency crash cart stored in the Yellow Zone. Review of the "Emergency Cart Checklist" stored on top of the crash cart revealed from August 01, 2014 to September 10, 2014, no available documentation on the following dates, the crash cart/defibrillator was checked daily per policy by ED staff (13 out of 41 days):
01. 08/04/2014;
02. 08/05/2014;
03. 08/06/2014;
04. 08/10/2014;
05. 08/11/2014;
06. 08/13/2014;
07. 08/16/2014;
08. 08/18/2014;
09. 08/18/2014;
10. 08/21/2014;
11. 08/25/2014;
12. 08/29/2014; and
13. 08/31/2014.
Interview during tour with ED Manager #1 revealed Equipment Room #4 was a clean supply room. Interview revealed the supplies were available for patient care use by staff. Interview revealed patient care supplies should not be stored on the floor. Interview confirmed the observation of supplies stored on the floor. Interview revealed the supplies should have been stored on the shelves and not on the floor. Further interview revealed emergency crash carts are to be checked daily by ED nursing staff and documented on the emergency cart checklist. Interview revealed the adult crash cart was available for patient care use by ED staff. Interview confirmed no available documentation the adult crash cart/defibrillator was checked on the dates listed. Interview confirmed hospital staff failed to follow hospital policies.

2. Observations during tour of the Hospital's satellite campus emergency department on 09/11/2014 at 0900 revealed Storage Room #1 used to store clean medical equipment and supplies. Observation revealed the following expired patient care supplies being stored in the bins/drawers with non-expired patient care supplies:
01. Two (2) 100 mL (milliliter) bags of Dextrose 5% IVF - expiration date 11/01/2013 (314 days expired).
02. One (1) 1000 mL bag of Dextrose 10% in Water IVF - expiration date 11/01/2013 (314 days expired).
03. One (1) 1000 mL bag of Dextrose 10% in Water IVF - expiration date 08/01/2014 (41 days expired).
Interview during tour with ED Manager #2 revealed the clean supplies in Storage Room #1 were available for patient care use by staff. Interview revealed no ED nursing staff is designated to check expiration dates on supplies being stored in the storage room. Interview revealed materials management staff are suppose to check expiration dates. Interview revealed ED staff are suppose to check the expiration dates when the supplies are pulled for use. Interview confirmed the above expired IVF were stored with non-expired IVF and should have been removed from the store room. Interview confirmed hospital staff failed to follow hospital policy.

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