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Based on observation, interview and record review the facility failed to maintain a current, accurate and complete medical record for 1 out of 3 patients reviewed. (Patient #1)

Findings include:
Record review documented that Patient #1 presented to the ED ( Emergency Department) on 10/14/2022 via EMS (Emergency Medical Services).

The Emergency Department provider note dated 10/14/2022 reads," This is a 66 year old female patient who presents to the ER via EMS. EMS states the patient has the patient was sent in by her significant other for chest pain. They noted her to be lethargic, sweating. They believe the pain started last night. Patient is oriented to person. She will answer some questions. She does point to her chest and tell me she has chest pain. On assessment she is noted to have abdominal pain. She is tachycardic. EMS reports other vital signs are within normal limits other than heart rate."

Review of physician orders dated 10/14/2022 at 1658 (4:58 PM) reads," Levophed 4 mg (milligrams)/250 ( milliliters) D5W ( an intravenous sugar solution), maintain MAP ( mean arterial blood pressure) 65-75 mmHg ( millimeters of mercury) initial rate if MAP less than 50 :10 mcg( micrograms) /min ( minute), if MAP is less than 60 mmHg titrate( increase) 1 mcg/min every 2 minutes, Maximum rate 30 mcg/min."

Review of the physician orders dated 10/14/2022 at 1926 ( 7:26 PM) reads, " Dopamine 400 mg Milligrams/D5W 250 ml, Initial rate 5 mcg ( micrograms)/kg( kilogram)/min( minute) titrate by 2.5 mcg/kg/min every 15 minutes. Maintain MAP between 60-65 mmHg. Maximum rate 20 mcg/kg/min."

Review of the Medication administration record document that Staff A, Registered Nurse ( RN) hung the Levophed at 1658 ( 4:58 PM) there is no documented rate of the initial rate.

Review of the Medication Administration Record documented that Staff A, RN hung the Dopamine at 7:26 PM.
Review of the vital signs for blood pressure( BP) documented the following blood pressures: at 6:45 PM BP was 50/30, MAP of 36, at 6:48 PM BP was 50/38, MAP 42, at 7:05 PM B/P was 57/41, MAP 46, at 7:35 PM BP was 65/47, MAP 53, at 7:39PM B/P was 60/45, MAP 50, at 7:55PM B/P was 49/28, MAP 35, at 7:58PM B/P was 79/47, MAP 57, at 8:04 PM B/P was 75/49, MAP 57, at 8:10 PM B/P was 63/48, MAP 53, at 8:15 PM B/P was 74/50, MAP 58, at 8:19PM B/P was 67/51, MAP 56, at 8:25 B/P was 37/22, at 8:28 PM B/P was 64/49, at 8:30PM B/P was 64/49, at 8:35 PM B/P was 64/49, at 8:39 PM B/P was 65/47, at 8:40 PM B/P was 54/30, at 8:42 PM B/P was 55/34, at 8:44 PM B/P was 55/30, and at 8:46 PM B/P was 55/30. There were no additional blood pressures documented in the medical record.
Review of the nursing documentation there were no entries in the medical record for titrating the Levophed or Dopamine.

During an interview conducted on 12/20/2022 at 11:00 AM, Staff B, Registered Nurse ( RN) stated, " I worked triage that day that she ( Patient #1) came in, we had 6 ambulances come in at the at the same time that day. She (Patient #1) was stable with abdominal pain. She was placed immediately into a bed. At first, she was assessed as an ESI (Emergency severity index) of 2 , but once she became unstable, when her blood pressure dropped she would have been bumped up to a ESI of 1. It is not appropriate for us to have no evidence of levophed or dopamine titration in the documentation. We should document titrations of medications per the doctor's orders in the medical record."

During an interview conducted on 12/20/2022 at 11:15 AM, Staff C, RN stated, " We do have an area where we will document titration of medications and we should always document those. I was not aware that they weren't documented on this patient. They should have been."

During an interview conducted on 12/21/2022 at 10:04 AM, Staff A, RN, stated, "I took care of [Patient #1's name], It was busy that day and my charge nurse was very helpful. [Medical Doctors name] was at nurses station and I would have a conversation and let him know about any concerns or developments and he would give new orders for her (Patient #1). I should have done the documentation about her drips (levophed and dopamine) and I can't tell you how much of anything that this patient was on based on my charting. I did titrate these medications and she was on maximum doses, but because I didn't document it I can't tell how much that was or when I did the titrations. I should have done that documentation."

Review of the policy and procedure titled "Assessment and Reassessment" approval date 10/2022 reads, "Purpose: 1. To establishing multidisciplinary process for obtaining appropriate and necessary information about each individual seeking entry into the facility for treatment and services.4. To Establish criteria for the reassessment of patients. 5. To determine the care, treatment, and services that will meet the patient's initial and continuing needs. Policy: A. General 2. Each patient seeking care or treatment in the emergency department shall receive an assessment by qualified individual so that a plan of care can be developed to best meet the needs of the patient. 6. Patient Needs will be reassessed throughout the course of care, treatment, and services. The frequency of reassessment is based on his or her plan of care or changes in his or her condition. Reassessment is also based on the patients diagnosis, desire for care, treatment, and services, response to previous care, treatment, and services, discharge planning needs, and his or her setting requirements. 3. Emergency Department: f. Patients are assessed Based on the triage priority. Nursing care is evaluated on a continual basis to determine the progress or lack of progress toward patient outcomes and patient goal attainment. Reevaluation is documented and plan of care is revised as appropriate prior to discharge of patient and according to patients needs and goals. Reevaluation may include, but is not limited to, recheck of vital signs, any change in status, and that there is no change in status from any previous evaluation. G. Reassessments shall be done anytime there is the following: 2) a significant change in vital signs, 3). to evaluate a treatment intervention."