HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff followed physician orders and facility policy related to assessing patients' vitals for 9 of 10 medical records (MR) reviewed (patients #1, 2, 3, 4, 5, 6, 8, 9 and 10).

Findings include:

1. Facility policy titled "...Emergency Department Manual" last reviewed/revised 11/21/18 indicated the following: "...Subject: Pediatric Policies...8. Documentation should include, but is not limited to the following: ...b. vital signs, including BP [blood pressure]...Vital Signs shall routinely be obtained on all patients by the nursing staff...

2. Facility policy titled "Emergency Nursing Standards of Practice" last reviewed/revised 11/12/19 indicated the following: "...Policy Category: Assessment of Patients...C. Standard 3: Implementation and Coordination of Care...7...Fundamental Emergency Department nursing interventions include, but are not limited to the following: a. Vital signs every 30 minutes on Level I & Level II patients, unless ordered more frequently. b. Vital signs every (1) hour on Level III, IV, & V patients, unless ordered more frequently..."

3. Facility policy titled "Triage" last reviewed/revised 11/26/19 indicated the following: "...Policy Category: Assessment of Patients...III. Procedure: A. At time of triage, the RN [Registered Nurse] will assess each patient, determine and document the level of care needed: 1. Life Threatening (I), 2. Emergent (II), 3. Urgent (III), 4. Less Urgent (IV), 5. Non-urgent (V)..."
1. Facility policy titled "...Emergency Department Manual" last reviewed/revised 11/21/18 indicated the following: "...Subject: Pediatric Policies...8. Documentation should include, but is not limited to the following: ...b. vital signs, including BP [blood pressure]...Vital Signs shall routinely be obtained on all patients by the nursing staff..."

4. Review of Patient #1's medical record indicated the following:
The patient arrived to the emergency department on 12/31/19 at 2105 hours, had a triage/acuity level of 3 and was transferred on 1/1/20 at 0125 hours.

a) On 12/31/19 at 2115 hours, Patient #1 had an oral temperature of 97.5 degrees F (Fahrenheit), heart rate of 162, respiratory rate of 42 and SpO2 (peripheral capillary oxygen saturation) of 100% on room air.

b) The medical record for Patient #1 lacked documentation of a complete set of vitals and/or refusals every hour including but not limited to a blood pressure on 12/31/19 at 2115, 2215, 2315 hours and on 1/1/20 at 0015 hours and a temperature on 12/31/19 at 2215 and 2315 hours.

5. Review of Patient #2's medical record indicated the following:
The patient arrived to the emergency department on 12/15/19 at 1359 hours, had a triage/acuity level of 5 until 1517 hours and then it was changed to a 3. Patient #2 was transferred on 12/15/19 at 1915 hours.

a) On 12/15/19 at 1408 hours, Patient #2 had a rectal temperature of 98.3 degrees F, heart rate of 171, respiratory rate of 24 and SpO2 of 95% on room air.

b) The medical record for Patient #2 lacked documentation of a complete set of vitals and/or refusals every hour including but not limited to a blood pressure on 12/15/19 at 1400, 1500, 1600, 1700, 1800 and 1900 hours, a heart rate, respiratory rate and temperature on 12/15/19 at 1500, 1600 and 1830 hours.

6. Review of Patient #3's medical record indicated the following:
The patient arrived to the emergency department on 2/3/20 at 1239 hours, had a triage/acuity level of 2 and was transferred on 2/3/20 at 1614 hours.

a) On 2/3/20 at 1246 hours, Patient #3 had a rectal temperature of 97 degrees F, heart rate of 177, respiratory rate of 46 and SpO2 of 83% on room air.

b) The medical record for Patient #3 lacked documentation of a complete set of vitals and/or refusals every 30 minutes including but not limited to a blood pressure on 2/3/20 at 1330 and 1400 hours and temperature on 2/3/20 at 1315, 1345, 1445, 1515 and 1545 hours.

7. Review of Patient #4's medical record indicated the following:
The patient arrived to the emergency department on 1/25/20 at 1837 hours, had a triage/acuity level of 3 and was transferred on 1/26/20 at 0122 hours.

a) On 1/25/20 at 1854 hours, Patient #4 had a rectal temperature of 100.2 F, heart rate of 156, respiratory rate of 54 and a SpO2 of 100%.

b) The medical record for Patient #4 lacked documentation of a complete set of vitals and/or refusals every hour including but not limited to a blood pressure on 1/25/20 at 1900, 2000, 2100 and 2200 hours.

8. Review of Patient #5's medical record indicated the following:
The patient arrived to the emergency department on 1/12/20 at 1617 hours, had a triage/acuity level of 3 and was transferred on 1/12/20 at 1835 hours.

a) On 1/12/20 at 1625 hours, Patient #5 had a temperature of 98.8 F, heart rate of 73, blood pressure of 108/79, respiratory rate of 18, and a SpO2 of 98%.

b) The medical record for Patient #5 lacked documentation of a complete set of vitals and/or refusals every hour including but not limited to a temperature on 1/12/20 at 1725 and 1825 hours.

9. Review of Patient #6's medical record indicated the following:
The patient arrived to the emergency department on 2/10/20 at 0956 hours, had a triage/acuity level of 3 and was transferred on 2/10/20 at 1348 hours.

a) On 2/10/20 at 1001 hours, Patient #6 had a temperature of 99.2 F, heart rate of 145, respiratory rate of 30, and a SpO2 of 95% on room air.

b) The medical record for Patient #6 lacked documentation of a complete set of vitals and/or refusals every hour including but not limited to a blood pressure on 2/10/20 at 1000, 1100, 1200 and 1300 hours, respiratory rate and temperature at 1100, 1200 and 1300 hours.

10. Review of Patient #8's medical record indicated the following:
The patient arrived to the emergency department on 12/9/19 at 0533 hours, had a triage/acuity level of 4 and was transferred on 12/9/19 at 1457 hours.

a) On 12/9/19 at 0536 hours, Patient #8 had an oral temperature of 98.8 F, heart rate of 120, SpO2 of 96% on room air.

b) The medical record for Patient #8 lacked documentation of a complete set of vitals and/or refusals every hour including but not limited to a blood pressure on 12/9/19 at 0536, 0630, 0730 and 1139 hours.

11. Review of Patient #9's medical record indicated the following:
The patient arrived to the emergency department on 12/18/19 at 0217 hours, had a triage/acuity level of 2 and was transferred on 12/18/19 at 0644 hours.

a) Patient #9 had a physician order for vital signs every 15 minutes while in the emergency department ordered on 12/18/19 at 0241 hours.

b) On 12/18/19 at 0304 hours, Patient #9 had a heart rate of 141, blood pressure of 102/60, respiratory rate of 15, SpO2 of 99% on a ventilator.

c) The medical record for Patient #9 lacked documentation of a complete set of vitals and/or refusals every 15 minutes including but not limited to a temperature on 12/18/19 at 0330, 0345, 0400, 0415, 0500, 0615 and 0630 hours.

12. Review of Patient #10's medical record indicated the following:
The patient arrived to the emergency department on 1/5/20 at 0548 hours, had a triage/acuity level of 1 and was transferred on 1/5/20 at 1131 hours.

a) On 1/5/20 at 0640 hours, Patient #10 had an axillary temperature of 97.9 degrees F.

b) The medical record for Patient #10 lacked documentation of a complete set of vitals and/or refusals every 30 minutes including but not limited to a temperature on 1/5/20 at 0800, 0830, 0900, 0930, 1000, 1030 and 1100 hours.

13. During an interview on 2/17/20 at 5:00 p.m., A5 (Quality Specialist) verified that the complete emergency department medical records for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 were provided.

14. During an interview on 2/18/20 at 4:10 p.m., A5 verified Patients #2, 3, 4, 5, 6, 8, 9 and 10 medical record information.

15. During an interview on 2/18/20 at 5:23 p.m., A2 (Vice President of Patient Care Services) verified that N2 (Registered Nurse) did not follow nursing standards for assessing/documenting vitals for Patient #1. A2 verified that how often a patient's vitals were assessed and documented depended on the patient's triage/acuity level, medications administered and if there was a physician order for frequency of assessing a patient's vitals. A2 verified Patient #1's medical record information.