HospitalInspections.org

Based on facility policy review, medical record, and electronic mail (email) correspondence, the facility failed to ensure Emergency Department (ED) staff followed their policy for vital sign assessments for 1 of 3 (Patient #1) sampled patients reviewed.

The findings included:

1. Review of the facility policy titled, "Emergency Services Standards of Care Policy," showed, "...Vital signs are indicators of the patient's current condition and must be evaluated in the context of the patient's overall health with serial measurements used to detect trends and to assess the effectiveness of interventions...8. Vital Signs shall be reassessed and documented within 60 minutes of departure from the ED for all patients - admitted, transferred, or discharged..."

2. Review of the ED log dated 12/19/19 showed Patient #1 arrived at 7:03 PM with complaints of "Unintentional ingestion-overdose" and was discharged home at 9:32 PM.

3. Review of the ED record for Patient #1 revealed a triage assessment including vital signs was completed on 12/19/19 at 7:17 PM. The Triage Note showed, Patient #1 ingested 3 laxative pills prior to arriving in the ED. The note also showed the patient had vomited once prior to her arrival.

Patient #1 was seen by the physician for a medical screening exam on 12/19/19 at 8:16 PM.

Review of the ED Disposition Summary dated 12/19/19 at 9:31 PM showed Patient #1 was discharged home in the care of her mother.

Review of the nursing Flowsheet showed Patient #1's vital signs were obtained on 12/19/19 at 7:15 PM. There were no other vital sign assessments documented.

4. In an email correspondence dated 2/28/2020, the facility's Quality Coordinator verified Patient #1's vital signs were only obtained once on 12/19/19 at 7:15 PM, and the patient was discharged at 9:31 PM, a total of 2 hours and 16 minutes later.