HospitalInspections.org

Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure all patients' cardiac monitors, pain, and vital signs, were assessed and reassessed by nursing staff according to facility policy. (Patient (P)1).

Findings include:

Facility policy titled, "Multidisciplinary Patient Assessment and Reassessment" last revised March 2024 states, " ...IV. Policy: ...E. The content of the initial assessment and ongoing reassessment is specific to the patient diagnosis and the complexity of care needs of the patient. F. Reassessment ensures that the treatment is dynamic, appropriate, and effective for the patient. G. Each patient is reassessed at regular intervals in the course of treatment to determine their response to care. In addition, patients are reassessed when there is a change in the level of care or a significant change in condition or diagnosis. Reassessment of patients with a change in level of care is provided by staff competent to provided that level of care .... Nursing Assessment and Reassessment Grid: ... Cardiac/Neuro Telemetry: Assessed by RN [registered nurse] immediately upon arrival .... Reassessment: Focused, problem-oriented reassessment every 12 hours or more frequently as indicted by the patient's condition. Continuous cardiac monitoring ...Vital Signs assessment/reassessment Schedule: ...Cardiac Telemetry: Upon admission; BP/P/R [Blood Pressure/Pulse/Respiratory Rate]: q4hr [every 4 hours]; temp [temperature]: q4hr; O2 Sat [Oxygen Saturation]: q4hr; Pain: At the time of Vital Signs and within 1 hour after intervention; Additional: Monitor rhythm strips on admission and every shift (8 hours) with written interpretation and RN initials ..."

On 1/14/25 at 11:48 AM, a review of P1's medical record took place in the conference room in the presence of Staff (S)7, Emergency Department (ED) Manager and S8, Pediatric ED Manager.

On 1/2/25, P1 presented to the ED at 12:06 PM with a chief complaint of upper abdominal pain radiating to chest and bilateral arms for two days. P1 was triaged at 12:07 PM by the triage nurse and assessed as an ESI (Emergency Severity Index) level 3. During triage, the nurse assessed P1's pain at a level 8 out of 10 in his/her upper abdomen. At 2:07 PM, a triage reassessment was completed by the triage nurse and no change in condition was identified. P1 reported his/her pain to be 7 out of 10. No pain interventions were documented in the medical record at this time. P1 had no change on ESI level or condition. At 2:17 PM, P1 was placed in a hallway bed. At 2:33 PM, P1 was seen by an ED provider and a full MSE was performed.

On 1/2/25 at 5:17 PM, an inpatient bed request was placed and at 6:44 PM an order for telemetry was placed.

On 1/2/25 at 6:52 PM, a nurse acknowledged this telemetry order. The medical record lacked documentation of placement of a telemetry monitor on the patient. S7 explained that when a nurse acknowledges an order, that means he/she completed the task. The medical record also lacked printed rhythm strips from admission, and every 8 hours, with the nurse's initials and interpretation of the rhythm. On 1/14/25 at 2:57 PM, S7 confirmed that no strips were found in the medical record as required per facility policy.

P1's pain was assessed every four hours, per facility policy, until 1/3/25 at 6:00 PM. After 6:00 PM, there are no further nursing assessments of P1's pain.

P1's medical record also revealed that vital signs were not completed every four hours, as per facility policy for cardiac telemetry.

Vital signs for P1 were documented on 1/2/25 at 6:29 PM and 1/3/25 at 12:00 AM. There are 5 hours and 31 minutes between the documented vital signs. Another set of vital signs were documented on 1/3/25 at 12:00 PM and the next set was not documented until 1/4/24 at 4:17 AM. There are 16 hours and 17 minutes between documented vital signs.

On 1/14/25 at 12:15 PM, the facility policy titled, "Multidisciplinary Patient Assessment and Reassessment" was reviewed with S3, Director of Regulatory Affairs, and S7. S3 and S7 confirmed that the facility policy dictates that P1's vital signs should have been completed every four hours. S7 confirmed P1's vital signs were not completed every four hours as indicated in facility policy.