HospitalInspections.org

Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure vital signs are documented in accordance with facility policy.

Findings include:

A review of Medical Record (MR) 1 was completed and revealed that Patient (P) 1 arrived to the Emergency Department on 06/20/24 for complaints of shortness of breath and an oxygen saturation (SpO2) reading of 69% without oxygen supplementation. He/She was subsequently admitted to the facility. The Nurse's admission assessment on 06/21/24 at 01:00 AM found P1 to be alert and oriented. Further review of MR 1 revealed the following:

The patient's last full set of vital signs prior to discharge on 06/23/24 were documented as follows:
8:00 AM - Heart Rate 95; Respiratory Rate 19, Blood Pressure 111/68, and SpO2 95%. There was no documented evidence as to what level of oxygen support the patient was receiving at that time, or if he/she was receiving oxygen support.

A physician's order to discharge the patient was placed on 06/23/24 at 10:00 AM. At 7:46 PM, eleven hours and forty six minutes after the full set of vital signed were documented, P1 left the facility by ambulance transportation. There was no documented evidence that a full set of vital signs was rechecked within four hours of the patient's discharge, as required by facility policy.

Review of the untimed Universal Transfer Form, dated 06/23/24, indicated that the patient was using 3L oxygen by nasal cannula when he/she was discharged. Documented vital signs on the Universal Transfer Form stated, "... BP: 111/68 P [Pulse] 95 R [Respirations] 18 T [Temperature] 98.5 ..." It was unable to be determined when the vital signs were checked.

During an interview on 08/23/24, Staff (S)12, the Registered Nurse, stated that on 06/23/24 they took one full set of vital signs the day of discharge at 08:00 AM. S12 stated that they did not check a full set of vital signs within four hours of P1's discharge from the facility.

Review of facility policy titled, "Discharge Planning Policy-UR Corp" (Policy Number 81996.1), effective 04/23/23, stated, "... 6) Nursing Discharge Assessment a) The nursing discharge assessment will be completed prior to discharge. This may include: ... ix) General status information for home health agencies, nursing home, assisted living, etc. (vital signs within 4 hours of discharge) ..."