HospitalInspections.org

41287

Based on document review and interviews the facility failed to ensure the facility health care services were furnished in accordance with appropriate written policies that were consistent with applicable State law. Based on document review and interviews the facility failed to ensure staff obtained patients vital signs per physician orders or unit protocol. The failure was identified in 6 of 6 inpatient medical records reviewed (Patients #1, #2, #3, #4, #5, and #7).


Facility policy:

According to the Acute Care Unit Guidelines for Care policy, revised 7/2019, patients receiving acute care were to have their vital signs obtained at least every 4 hours. Routine vital signs for adult patients included heart rate, blood pressure, respiratory rate, SpO2 (blood oxygen level) and temperature. For pediatric patients, vital signs included heart rate, respiratory rate, SpO2, temperature, and once a day, a blood pressure and a Pediatric Early Warning Score (PEWS) (a scale which identifies pediatric patients at risk for deterioration).

1. The facility failed to ensure patients had their vital signs obtained per physician orders or unit protocol.

a. A medical record review was conducted for Patient # 5 who arrived to the ED on 9/13/19 due to low blood oxygen levels related to influenza A (a respiratory infection commonly known as the flu).

On 9/13/19 at 10:11 a.m., the patient's provider ordered vital signs to be completed every 4 hours.

Review of the record found no evidence the patient's vital signs were obtained from 9/14/19 12:33 a.m. to 6:24 a.m., which was 2 hours and 27 minutes beyond the ordered 4 hour time frame.

b. A medical record review was conducted for Patient #1 admitted on 8/8/19 for treatment of pneumonia.

Review of the Nursing Order section found the patient's provider ordered vital signs to be completed every 4 hours. The order was entered by the provider on 8/8/19 at 10:37 a.m.

Review of the Flowsheet Vitals from 8/8/19 at 10:19 a.m. to 8/10/19 at 10:52 a.m., revealed vital signs were not completed every four hours as ordered. The record review found no evidence the patient's vital signs were obtained from 8/8/19 at 12:55 p.m. to 7:08 p.m., a period of 2 hours and 13 minutes beyond the 4 hour ordered time frame. Additionally, vital signs were not obtained on 8/9/19 from 12:55 a.m. to 5:36 a.m. and 6:24 a.m. to 12:01 p.m. which was 41 minutes and 1 hour and 37 minutes, respectively, beyond the 4 hour timeframe.

c. A medical record review was conducted for Patient #3 admitted on 9/16/19 for worsening of his chronic obstructive pulmonary disease (COPD) ( a progressive group of lung diseases which obstruct airflow), pneumonia and low blood oxygen levels.

Review of the medical record revealed the physician ordered vital signs to be obtained every four hours on 9/16/19 at 9:28 a.m.

Review of the flowsheet vital signs found no evidence of vital signs on 9/16/19 from 4:05 p.m. to 9:53 p.m., 1 hour and 48 minutes beyond the four our specified timeframe. Additionally, the medical record revealed no evidence of vital signs on 9/18/19 from 7:58 a.m. to 12:45 p.m., which was 47 minutes beyond the 4 hours as ordered.

d. Similar findings were identified in medical records of Patient #2, Patient #4 and Patient #7, who were admitted as inpatient from 8/12/19-9/5/19.

e. On 9/18/19 at 3:18 p.m., an interview was conducted with Registered Nurse (RN) #1. She stated vital signs were completed every four hours on patient's who were admitted to acute care. She stated the facility provided the staff with a card to attach to their badges which specified the expectations of charting for vital signs for inpatients in acute care.

f. On 9/18/19 3:37 p.m., an interview was conducted Certified Nursing Assistant (CNA) #2. She reiterated vital signs were to be taken every four hours unless otherwise ordered by the physician. She stated when she started a shift she would look at the patient's notes and when the last time the vital signs were obtained in order to determine when the next set was needed. Furthermore, she stated if a patient were to refuse their vital signs being taken, she would document the refusal in the notes.

g. An interview was conducted with Chief Nursing Officer (CNO) #3 on 9/19/19 at 3:45 p.m. CNO #3 stated vital signs were obtained to assess the hemodynamic (the dynamics of a person's blood flow) stability and was an important part of patient assessment. She stated, vital signs consisted of temperature, heart rate, blood pressure, blood oxygen levels, heart rhythm if on a heart monitor and pain level. CNO #3 stated staff were to obtain the patients' vital signs per the provider's orders and unit protocol.

CNO #3 reviewed the medical records for Patients #1, #2, #3, #4, #5, and #7 and confirmed vital signs were not consistently completed per the physician orders.