HospitalInspections.org

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Based on observations, review of hospital policies and procedures and interviews with staff, the hospital failed to implement policies and procedures that guide staff on vital signs assessments and reporting abnormal vital signs to the provider for 1 of 5 patient records reviewed (Patient #1).

Failure to develop and implement effective hospital policies and procedures and ensure staff notify providers of abnormal vital signs places patients at risk of harm, including death, due delayed or inadequate care.

Findings included:

1. A review of the hospital policy and procedures titled, "Emergency Care Standards," last reviewed 10/24, showed that each patient is assessed for the severity of their medical condition upon presentation to the emergency department (ED). The assessment determines how often vital signs should be taken. Any abnormal findings need to be reported to the attending physician.

2. A review of patient records showed the following:

On 10/24/24 at 8:38 AM, Patient #1 arrived at the ED with a blood pressure (BP) of 215/140 (normal range between 90/50 and 120/80). The investigator found no documentation showing that staff notified the provider of the abnormal BP reading.

Nursing documentation showed that at 9:01 AM, Patient #1's BP remained elevated at 214/122. The investigator found no documentation showing that staff notified the provider of the abnormal BP reading.

At 9:30 AM, nursing documentation showed that Patient #1 continued to request pain medication for a headache and verbalize concern about the high blood pressure readings and that staff updated the provider.

At 10:10 AM, nursing documentation showed that staff administered the first dose of medication to treat the patient's high blood pressure.

At 11:57 AM, Patient #1 was transferred to a higher level of care via Lifeflight helicopter for treatment of a cerebral aneurysm (a weakened area in a blood vessel in the brain that if ruptured, may cause severe bleeding within the brain and death).

3. On 03/04/25 at 3:30 PM, an interview with the ED Assistant Nurse Manager (Staff #1) showed that it is the expectation that staff will notify providers when vital signs are out of normal parameters. The Investigator asked Staff #1 for a policy containing direction to staff for abnormal vital signs and notifying the provider when blood pressure or vital signs fall outside normal limits. Staff #1 stated the information is covered in the ED Standards of Care and is part of the new ED nurse unit orientation.

4. On 03/06/25 at 10:00 AM, the ED Educator (Staff #2) provided the Investigator with an overview and demonstration of the new ED nurse department specific education during weeks 1 and 3, including education of normal vital signs parameters and expectations. Staff #2 stated that any abnormal vital signs should be reported to the provider and documented. The Investigator asked for a policy containing staff guidance for hypertensive patients, abnormal vital signs, and provider notification, Staff #2 stated staff are taught that it is "best practice" to notify provider of vital signs not within normal limits. Staff #2 was unable to provide the Investigator with the requested policy.