HospitalInspections.org

Based on facility policy review, medical record review and interview, the facility failed to obtain vital signs and perform assessments on an ongoing basis for 3 patients (Patient #11, #14 and #17) of 31 patients reviewed.

The findings include:

Review of the facility policy titled, "Patient Initial Assessment and Reassessment," revised 7/14/2023, revealed "...Inpatients will be reassessed each shift...and upon transfer from one nursing unit to another..."

Review of the facility policy titled, "Nursing Assessment In The Emergency Department-Triage-Primary-Ongoing and Disposition," revised 12/6/2024, revealed "...Upon arrival of the patient to the treatment area, a medical screening exam will be performed along with ongoing vital signs, assessment..."

Patient #11 was admitted to the facility on 11/29/2023, for an aortic valve replacement procedure. The patient's medical diagnoses included Severe Aortic Valve Stenosis, Peripheral Artery Disease, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Dependence on Supplemental Oxygen, Alcohol Abuse and Lifelong Smoker.

Medical record review revealed Patient #11 had an admission nursing assessment on 11/29/2023 at 7:30 AM.

Review of an Interventional Radiology Pre-Procedural document for Patient #11, dated 11/29/2023 at 8:20 AM, revealed "...AS (aortic stenosis) that has recently progressed to severe..."

Medical record review revealed Patient #11 had a post anesthesia care nursing assessment on 11/29/2023 at 12:44 PM.

Review of a nursing progress note for Patient #11, dated 11/29/2023 at 2:00 PM, revealed "...Report called to [Registered Nurse-RN B]. Patient taken to [Patient's room number]...Relinquish care to [RN B]..."

Medical record review for Patient #11 revealed no evidence to indicate a nursing assessment was performed for Patient #11 by RN B, upon arrival to the cardiac step down unit, from the post anesthesia care unit.

Medical record review revealed a nursing assessment was performed for Patient #11 by the night shift nurse on 11/29/2023 at 7:30 PM (6 hours and 46 minutes after previous assessment).

During an interview on 1/8/2025 at 11:16 AM, the Cardiac Step Down Unit Nurse Manager stated the standard was for the RN to perform a full assessment on any patient admitted to the floor within 30-60 minutes of their arrival. The Cardiac Step Down Unit Nurse Manager confirmed there was no evidence RN B performed a nursing assessment upon Patient #11's arrival to the cardiac step down unit.



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Medical record review revealed Patient #14 presented to the Emergency Department (ED) by ambulance on 2/2/2024 at 10:42 AM, with complaint of abdominal discomfort, nausea, and vomiting. Patient #14 was triaged (assessment to determine the urgency for treatment and type of treatment needed) at 10:46 AM with an Emergency Severity Index (ESI-a 5 level system used to categorize Emergency Department patients) score of 3 (urgent-not life threatening). The patient received a medical screening exam (MSE) by a qualified medical provider (QMP) while in triage. Vital signs were performed at 10:52 AM, with temperature of 97.2 degrees Fahrenheit (F), heart rate 73, respirations 20, blood pressure 129/48, and oxygen saturation 99% in room air. Patient #14 was taken to the ED waiting room at 10:53 AM.

Review of a CT (computed tomography-detailed x-ray) of abdomen/pelvis report for Patient #14 dated 2/2/2024 at 11:52 AM, revealed "...IMPRESSION: Findings consistent with early or partial small bowel obstruction [blocked]..."

Medical record review revealed Patient #14 returned to the ED waiting room at 11:55 AM, after the CT scan was completed.

Medical record review for Patient #14 revealed no evidence to indicate rounding with vital signs were performed for Patient #14 while he waited in the ED waiting room on 2/2/2024 from 11:55 AM- 5:18 PM (5 hours and 23 minutes).

During an interview on 1/7/2025 at 10:15 AM, the ED Director stated the standard was for staff to round on patients to include vital signs every 2 hours if the patient had been in the waiting room greater than 2 hours. The ED Director confirmed there was no evidence rounding with vital signs had occurred for Patient #14 while he waited in the ED waiting room on 2/2/2024 from 11:55 AM-5:18 PM.

Medical record review revealed Patient #17 presented to the ED on 9/12/2024 at 2:38 PM, with complaint of lethargy (lack of energy) which began at approximately 1:00 PM. The patient was triaged at 2:59 PM with an ESI score of 3. A MSE was initiated by a QMP in triage. The patient had a cough with yellow sputum production since the previous Friday. The patient's pacemaker had been changed on Friday 9/6/2024. The patient reported headache and "...some left arm pain..." but denied other pain. Patient #17 was alert, but lethargic, and answered questions. Vital signs were performed at 3:01 PM, with temperature 98.3 F, heart rate 60, respirations 22, blood pressure 124/57, and oxygen saturation 96% while receiving oxygen by nasal cannula at 3 liters/minute.

Medical record review revealed diagnostic tests were performed for Patient #17 on 9/12/2024 between 3:36 PM and 3:56 PM.

Review of ED event documentation for Patient #17 revealed the patient was in "results waiting" (ED waiting room) from 4:28 PM-9:27 PM.

Review of an ED Patient Care Timeline for Patient #17 on 9/12/2024 at 9:36 PM, revealed the ED received a call from another hospital ED stating Patient #17 had presented to their ED for treatment. Continued review revealed "...patient [#17] removed from [ED] board...[9:37 PM]...ED Disposition set to LWBS [left without being seen] after triage..."

Review of the medical record for Patient #17 revealed no evidence to indicate rounding with vital signs were performed for Patient #17 while she waited in the ED waiting room on 9/12/2024 from 4:28 PM until it was determined she left without being seen at 9:36 PM (5 hours and 8 minutes).

During an interview on 1/7/2025 at 10:15 AM, the ED Director stated the standard was for staff to round on patients to include vital signs every 2 hours if the patient had been in the waiting room greater than 2 hours.