HospitalInspections.org

Based on review of hospital policy, medical records and interview, the nursing staff failed to assess vital signs per physician orders for 2 of 2 sampled ambulatory surgical patients.

Findings include:

Review on 06/04/2025 of the hospital policy titled "Vital Sign Assessment" effective date 05/2022, revealed "Blood pressure, pulse, respirations, and temperature will be taken on all patients as ordered by the provider. ..."

1. Review on 06/03/2025 of the medical record for Patient #11 revealed a 38-year-old female that presented to the ambulatory surgical center on 04/10/2025 at 0745 for a "Robot Assisted Total Laparoscopic Hysterectomy". Review of the physician post-operative orders to follow the post-op cesarean section order set, dated 04/10/2025 at 1128 revealed an order to obtain vital signs every hour times 4 (1128-1528) and then obtain every 4 hours beginning at 1528. Review of the nursing vital signs documentation flowsheet revealed vital signs to include temperature, pulse, respirations and blood pressure were obtained at 1131, 1201 and 1202. Vital signs documented at 1232, 1332 and 1432 failed to include the patient's temperature. Record review failed to reveal a complete set of vital signs was documented every hour times four from 1131 - 1432. Review of the vital signs flowsheet revealed the first set of every 4 hours vital signs was documented at 1532 and failed to include a temperature. Vital signs documented at 1935 included temperature, pulse, respirations and blood pressure. Review of the medical record revealed that Patient #11 returned to the operating room at 2052 for surgical complications. Review of the physician post-operative orders to follow the post-op cesarean section order set, dated 04/10/2025 at 2206 revealed an order to obtain vital signs every hour times 4 (2206-0206 [4/11/25]) and then obtain every 4 hours beginning at on 04/11/2025 at 0206. Review of the nursing vital signs documentation flowsheet revealed vital signs to include temperature, pulse, respirations and blood pressure were obtained at 2210, 2240 and 2252. Vital signs documented at 2215 and 2220 failed to include the patient's temperature. Vital signs flowsheet review revealed the next complete set of vital signs was obtained at 0343. Record reviews failed to reveal that a complete set of vital signs was documented every hour times four from 2206-0206. Review of the vital signs flowsheet revealed there was no documentation of the first set of every 4 hours vital signs (should have been documented on 04/11/2025 at 0606). Vital signs flowsheet review revealed documentation of a temperature at 0716 and 1000 with no pulse, respiration or blood pressure documented. The next set of vital signs was documented at 1445 (time of discharge). The nursing staff failed to document a complete set of vital signs every hour times four and then every 4 hours as ordered by the physician.

Interview on 06/04/2025 at 1100 with RN #1 revealed the nursing staff were expected to follow the physician orders for obtaining vital signs. The vital signs should include temperature, pulse, respiratory rate and blood pressure. The interview revealed the staff failed to obtain vital signs per the physician order and failed to follow the hospital policy.

2. Review on 06/04/2025 of the medical record for Patient #20 revealed a 44-year-old female that presented to the ambulatory surgical center on 04/10/2025 at 0516 for a "Robot Assisted Total Laparoscopic Hysterectomy". Review of the physician post-operative orders to follow the post-op cesarean section order set, dated 04/10/2025 at 0920 revealed an order to obtain vital signs every hour times 4 (0920-1320) and then obtain every 4 hours beginning at 1320. Review of the nursing vital signs documentation flowsheet revealed vital signs to include temperature, pulse, respirations and blood pressure were obtained at 0919, 0949 and 0950. Vital signs documented at 1030, 1230 and 1300 failed to include the patient's temperature. Record review failed to reveal that a complete set of vital signs was documented every hour times four from 0920 - 1305 (time of discharge). The nursing staff failed to document a complete set of vital signs every hour times four as ordered by the physician.

Interview on 06/04/2025 at 1100 with RN #1 revealed the nursing staff were expected to follow the physician orders for obtaining vital signs. The vital signs should include temperature, pulse, respiratory rate and blood pressure. The interview revealed the staff failed to obtain vital signs per the physician order and failed to follow the hospital policy.