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Based on record review and interview the facility's Registered Nurses failed to provide nursing care and services to 6 of 25 (#2, #7, #8, #10, #19 and #20), as per the facility's Policies and Procedures. Failure to provide care and services as per the facility's Policies and Procedures may result in patients being discharge without being stable.

Findings:

Review of the facility's Policy and Procedures entitled, "Vital Signs," revealed it has been effective since January 2003, with a revision date of March 2009. Further review of this policy revealed, "5. All patients within department should have vital signs rechecked every 2 hours if stable. 6. If vital signs are abnormal, vital signs should be rechecked at minimum every hour. 7. All patients admitted to hospital or transferred to another facility should have vital signs recorded prior to leaving the Emergency Department."

Review of the facility's Policy and Procedures entitled, "Nursing Assessment," revealed it became effective on January 2003 with the last revision on March 2009. Further review of this policy revealed, "Continue to document ongoing assessment during treatment in the Emergency Department."

Review of Patient #2's record revealed the patient presented to the Emergency Room (ER) on 01/25/2010 at 1:13 PM after a fall that resulted in a laceration to the patient's forehead. The patient's vital signs (VS) were taken at 1:13 PM and recorded as blood pressure (BP) 175/86; pulse 81; respirations 18; and temperature 97.3. Further record review failed to reveal any other VS until the time of discharge at 4:46 PM which is recorded as BP 175/86; pulse 81; respirations 18 and no temperature was taken.

A telephone interview was conducted with Patient #2 on 3/4/10 at 3:20 PM to verify the care given in the emergency department. The patient was asked how many times were his/her vital signs taken while in the emergency department. The patient stated, "they took it once. I stayed in the waiting room the whole time except for the time I was being attended to. They had to put a couple of stitches in."

Review of Patient #7's medical record revealed the patient presented to the ER on 01/27/2010 with the chief complaint of head injury, lost of vision and vomiting. Further review of patient #7 record revealed the patient was triaged at 22:11 (10:11 PM) with VS of BP 118/69; temperature 96.9; heart rate 99; respiratory rate 18; and oxygen saturation 99% on room air. While in the ER, the patient was ordered and received acetaminophen-oxycodone. Review of the, "Emergency Department Nursing Assessment Form" revealed the patient did not have his/her vital signs reassessed until over four hours later at 02:40 (2:40 AM), when the patient was discharged from the ER. Patient #7 was discharged from the ER with a diagnosis of head injury with a concussion and VS of pulse rate of 82; respiratory rate 18; and BP 118/69. Comparison of the triage and discharge vital signs revealed them to be identical.

Review of Patient #8's medical record revealed the patient presented to the ER on 01/28/2010 with chief complaint of shortness of breath. Review of patient #8's Triage Form revealed the patient was triaged at 06:37 (6:37 AM). Further review of patient #8's Triage Form revealed the patient's vital signs (VS) were: blood pressure (BP) 124/70; temperature 97.8; heart rate 86; respiratory rate 22; oxygen saturation 98% on room air. Review of the Assessments form revealed that patient #8 received a pretreatment assessment at 07:45 (7:45 AM) which indicates the patient's respiratory rate was 14, pulse was 73 and oxygen saturation was 94%. Further review of patient #8's record revealed the physician ordered the patient to receive levofloxacin 750 milligrams (mg) 150 milliliter (mL) injection, codeine-guaifenesin 10mL syrup, albuterol 2.5 mg, 3mL solution, nebulizer treatment, and an intravenous (IV) insertion. The next set of VS, for patient #8, was not taken for over 2 hours at 11:00 AM were: respiratory rate 22; oxygen saturation 98; and BP 124/70. Review of patient #8's discharge VS revealed the patient was discharged from the ER at 11:00 AM, with a diagnosis of pneumonia and acute dyspnea. According to this section of the patient's record, the patients VS were: pulse 86; respiratory rate 22; oxygen saturation 98% on room air; and BP 124/70. Comparison of the triage and discharge VS revealed they were exactly the same, even though the patient had received treatment and several medications while in the ER.

Review of patient #10's medical record revealed the patient presented to the ER on 01/29/10 with a chief complaint of shoulder injury. Further review of the patient's record revealed the patient was triaged at 00:33 (12:33 AM) with VS taken and recorded as BP 124/79; pulse 100; respiratory rate 18; and temperature 99.8. There are no other documented vital signs until discharge at 02:51 (2:51 AM) and recorded as BP 124/79; pulse 100; respiratory rate 12; and temperature 98.0.

Review of Patient #19's medical record revealed the patient present to the ER on 02/08/2010 with a chief complaint of abscess of three teeth. Further review of this record revealed the patient was triaged at 4:57 PM, with the VS recorded as BP 129/56; pulse 79; respiratory rate 18; and temperature of 98.6. The next set of documented vital signs were documented at the time of discharge, at 6:35 PM, with the VS documented as BP 129/56; respiratory rate of 18, but no documented temperature or pulse.

Review of Patient #20's medical record revealed the patient presented to the ER on 02/08/10 after suffering a fall. According to Patient #20's record, he/she was triage at 17:37 (5:37 PM) with VS recorded as BP 144/92; pulse 80; respiratory rate of 18; and temperature of 98.9. Further review of this record revealed that Patient #20 received medication for pain at 20:00 (8:00 PM). The patient's next set of vital signs were at discharge at 21:26 (9:26 PM), almost four hours after triage, were recorded as BP 145/no reading; there was no pulse or temperatures recorded; and a respiratory rate of 18.

Interview on 03/04/2010 at 9:55 AM with the facility's Director Critical and Clinical Information revealed the ER has two methods for taking patients' vital signs and placing the information in to the computer system. According to the interview, a patient can be placed on an electronic monitor that will take the patient's vitals and automatically placed the information in to the patient's record or a nurse can take the patient's vital signs and manually placed the information in to the patient's record. The Director was then asked if the computer system would automatically pull the last set of VS and list them as the discharge vital signs, in the event the nurse has not placed that information in the computer, at the time the patient's record is closed. The Director stated that the automatic system would not do that as it is set to take the vital signs and record them, if the last vital signs were taken at 11 AM then it would only show up as being taken at 11 AM. Further interview revealed that if the nurse did not take the discharge vitals or did not input the information into the patient's record, then the discharge vital signs will remain blank.

During the 03/04/2010, 10:10 AM interview with the ER Director, she was asked how often should patients' vital signs be taken. According to the ER Director every patient should have their vital signs taken at triage, every two hours or more specific for the patient's current condition, and at discharge. When it was pointed out that several patients appeared to be discharged from the ER with the same exact vital signs they were triaged with, even after receiving treatment, the Director was unable to confirm whether the nurses were following the policies and procedures related to vital sign protocol.

Review of the facility's "Patient Care Services Job Description/Performance Appraisal," for Charge Registered Nurse (RN) revealed a section entitled, "B. Performance of Essential Function." Review of this section revealed a line entitled: "4) Nursing documentation". According to this line, a Charge RN is to, "Provide ongoing evaluation and support of documentation process to ensure completeness, legibility and professional presentation."