HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the implementation of the patient's plan of care by failing to follow physician's orders for 1 of 7 sampled patients (#7). Findings:

Review of Patient #7's medical record revealed the patient was admitted to the hospital on 6/30/2010 with diagnoses that included Delirium, Polysubstance Dependence, and Mood Disorder. Further review revealed a physician's order dated 6/30/2010 at 1:15 p.m. for "Vital signs: Monitor blood pressure and pulse every hour for pulse greater than 100 or blood pressure greater than 150/100. Once stable on 2 successive hourly readings recheck in 3 hours, then monitor every 6 hours if still stable. Return to every hour pulse and blood pressure if parameters are exceeded. Take manual blood pressure and apical pulse if blood pressure is greater than 150/110 or less than 90/60 or pulse is greater than 110 or less than 60."

Review of Patient #7's electronically documented pulse revealed the following:
7/01/2010: 9:35 a.m. pulse 108; 12:00 p.m. (2 hours and 55 minutes after last pulse greater then 100) pulse 120; 2:00 p.m. (2 hours after last pulse greater than 100) pulse 101; 4:00 p.m. (2 hours after last pulse greater than 100) pulse 111; 6:15 p.m. (2 hours and 14 minutes after last pulse greater than 100) pulse 120; 8:00 p.m. (1 hour and 45 minutes after last pulse greater than 100) pulse 120; 10:51 p.m. (2 hours and 51 minutes after last pulse greater than 100) pulse 100.

During an interview on 7/02/2010 at 1:15 p.m., Mental and Behavioral Health Administrator S2 and Registered Nurse S20 confirmed that Patient #7's vital signs had not been monitored at the frequency ordered by the patient's physician. Both (S2 and S20) indicated the patients vital signs should have been monitored at a frequency of every one hour when the patient's heart rate exceeded 100.