HospitalInspections.org

Based on document review, medical record review and interview it was revealed the facility failed to follow policies and procedures for performing vital signs and hourly rounding on one (1) of ten (10) patients (patient #1) on the telemetry unit. The failure to perform vital signs and hourly rounding per policy has the potential to adversely affect all patients on the telemetry unit.

Findings include:

A review of the facility policy entitled "Guideline: Vital Signs," last revised 7/31/20, revealed in part: "On the PCU (Patient Care Unit-2nd and 6th floor Tele), unless otherwise specifically ordered by the physician, all patients will have their vital signs (VS) obtained Q4 (every 4) hours ...Every 4 hour vitals are 0000, 0400, 0800, 1200, 1600, 2000."

A review of the facility policy entitled "In-Patient Rounding," last revised 2/2/17, revealed in part: "Rounding should occur hourly at least 80% of the time ...Clinical Staff (Nurses and/or Patient Care Technicians) will enter each patient's room on at least an hourly basis, when able ..."

A review of patient #1's medical record revealed vital signs were ordered every four (4) hours. Vital signs were documented on 11/14/21 at 8:26 a.m. There were no vital signs documented for 12:00 p.m. or 4:00 p.m. on 11/14/21.

A review of patient #1's medical record revealed "Hourly rounds completed" was not documented on 11/14/21 during the day shift time frame.

An interview conducted with the Nurse Manager (NM) for the telemetry and stepdown unit on 1/20/22 at 10:30 a.m. revealed there was one patient care technician (PCT) on the floor that day (11/14/21). The nurse did not know the vital signs had not been done at noon. The nurse was in the patient's room at 4:00 p.m. and saw the PCT across the hall and thought the PCT would do the vital signs. The PCT saw the nurse in the room and thought the nurse would get the vital signs. The NM said the nurse and PCT did not communicate.
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A telephone interview conducted with Registered Nurse (RN) #2 on 1/20/22 at 11:00 a.m. revealed RN #2 had been in patient #1's room at 4:00 p.m. to give medicine. RN #2 stated they asked the PCT if they needed help getting the vital signs and they said they had them all so RN #2 did not realize patient #1 had not had vital signs taken for 4:00 p.m. It was hectic that day. RN #2 stated they tried to round every hour. They had a patient whose oxygen saturations were dropping and needed close monitoring, a patient had to be moved due to a plumbing issue and another nurse had asked for assistance during the time between when RN #2 had made rounds at 4:00 p.m. and the end of the shift. RN #2 stated they usually document rounding when they document their assessment.

An interview was conducted with the NM on 1/20/22 at 10:30 a.m. and she agreed vital signs and hourly rounding were not completed according to hospital policy.