HospitalInspections.org

Based on record review and interview, the facility failed to ensure ongoing assessment of patient needs by obtaining patient vital signs according to facility policy and procedure for 1 (#1) of 1 patients resulting in the potential for unidentified and unmet patient needs. Findings include:

Review of Patient #1's medical record on 1/14/2020 at 1525 revealed Patient #1 was a 9-year old female sent to the emergency department (ED) by community mental health on 12/13/2019 and was admitted for increased aggression and psychiatric evaluation. The patient was kept in the emergency department for four days waiting placement for in-patient treatment.

Review of vital sign documentation revealed the vital signs were obtained on the following dates and times:

On 12/13/2019 at 1539 and 2315
On 12/14/2019 at 0010, 0630, 0830, and 1908
On 12/15/2019 at 0943 and 1757
On 12/16/2019 at 0600
On 12/17/2019 at 0130, 0837, and 1347

Review of physician's orders revealed no order was present for when to obtain vital signs.

ED Manager Staff I was queried on 1/15/2020 at 0935 as to how often vital signs should be obtained in the ED when there is no order from the physician. Staff I explained, in most cases, orders for obtaining vital signs in ED were not given as it would vary greatly based on the acuity of the patient and the fast-paced nature of the department. She further stated it was her expectation as well as facility policy when a patient was "boarded" in the ED for psychiatric in-patient placement that vital signs be obtained every 8 hours.

Facility policy #TX.119 titled "Suicidal Patient, Assessment and Care" last revised 5/4/2018 states, "ED holds-any behavioral health patient that needs inpatient behavioral health and there are no current beds available...Vitals must be obtained every 8 hours, after any medication or treatment that would require a repeat vital sign and with any change in condition..." This had not been done.