HospitalInspections.org

Based on a review of clinical records, facility documentation and an interview with staff, the director of the nursing service failed to be responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital.

Findings were:

In an interview with staff #7 on 11-7-17, staff #7 stated that she had been the house supervisor on duty at the time of patient #1's request to be discharged on 6-10-17. Staff #7 was asked why there was no documentation of her conversation with patient #1 in the clinical record and staff #7 stated that it was probably because she had been "busy". Staff #7 stated that she had gone into the electronic system and filled out an incident report regarding the event and patient #1's complaint at the time, but failed to document in the clinical record. Staff #7 was asked to provide the surveyor with a written statement outlining her conversation with Mr. Reeves on the evening of 6-10-17 and did so.

Facility job description for House Supervisor describes the position as follows:
"Coordinates and supervises the organization and administration of nursing services and all nursing units for designated shift. The Nursing Service House Supervisor is responsible for efficient functioning of hospital personnel on the shift and will perform administrative and related duties in the absence of the Nursing Vice Presidents, Senior Nursing Vice Presidents, and Patient Placement Director. Evaluates patient care and
staffing and recommends to Nursing Administration changes necessary for improved patient care. Integrates the patient's total patient care with other departments; coordinates shift activities of other hospital departments in the absence of administrative personnel. Has a working knowledge of organizational and nursing policies."

Facility policy HA-206.0 titled "Charting on Clinical Record/General Nursing Units states, in part:
"Statement of Purpose: It is the policy of University Medical Center to accurately record all patient care provided, nursing observations, the patient's response to treatment, as well as outcomes of the care provided.
...
I. UMC specifics
...
C. The following information is documented in the electronic record and on approved forms that are specific to tasks or procedures ...The following information should be documented in the clinical record.
...
9. All participation in care by the patient and/or significant other.
...
11. Observations relevant to patient's diagnosis and condition, including physical, emotional, and psychosocial aspects."

The clinical records for 10 ED (emergency department) patients (patients #1 - #10) were reviewed. The date of service for patient #1 was 6-9-17 and the dates of service for patients #2 - #9 ranged from 11-1-17 through 11-3-17. During a review of the 10 clinical records, 9 of the 10 patients (patients #1 - #9) had not had their vital signs reassessed at the appropriate intervals specified by facility policy.

Patients #6 & #8 were assigned an ESI II level upon triage (requiring their vital signs to be reassessed hourly until discharge). Vital signs were reassessed as follows:

-Patient #6 arrived in the ED at 9:09 am. Vital signs were reassessed at 11:16 am and the patient was discharged at 1:32 pm.

-Patient #8 arrived in the ED at 2:47 am. Vital signs were reassessed at 5:07 am and the patient was discharged at 5:53 am.

Patients #1, #2, #3, #4, #5, #7 and #9 were assigned an ESI III level upon triage (requiring their vital signs to be reassessed every 2 hours until discharge). Vital signs were reassessed as follows:

-Patient #1 arrived in the ED at 6:57 pm. Vital signs were reassessed at 1:01 am the next morning and again at 3:00 am and 4:39 am until he was admitted to the inpatient unit at 5:20 am.

-Patient #2 arrived in the ED at 2:01 pm. Vital signs were reassessed at 6:18 pm and 8:00 pm. The patient was discharged at 8:53 pm.

-Patient #3 arrived in the ED at 5:27 pm. Vital signs were reassessed at 8:08 pm, 10:55 pm, 11:37 pm and upon discharge at 1:01 am.

-Patient #4 arrived in the ED at 4:13 pm. Vital signs were reassessed at 7:06 pm and the patient was discharged at 7:09 pm.

-Patient #5 arrived in the ED at 9:31 pm. Vital signs were reassessed at 1:35 am, 3:28 am and 6:35 am. The patient was discharged at 7:21 am.

-Patient #7 arrived in the ED at 9:21 pm. Vital signs were reassessed at 12:51 am and 2:11 am. The patient was discharged at 5:00 am.

-Patient #9 arrived in the ED at 6:34 am. Vital signs were reassessed at 10:43 am and the patient was discharged at 12:39 pm.


Facility policy 903.0 titled "Emergency Center Standard of Care" states, in part:
"II. Assessment:
...
C. A complete set of vital signs, patient status form, Glasgow Coma Scale and intake and output (I&O) will need to be obtained based on ESI level given, admission status, a change in patient status, or when clinically indicated.
a. Level 1: Red Acuity
i. V/S [vital signs]: at minimum Q30min [every 30 minutes] or more frequently as needed
ii. GCS [Glasgow coma scale], patient status, and I&O: Q1hr
b. Level 2: Orange Acuity
i. V/S, GCS, I&O and patient status Q1hr
c. Level 3. Yellow Acuity
i. V/S, GCS, I&O and patient status: Q2hr"

Facility policy 1002.0 titled "Triage Classification and Utilization" states, in part:
"Procedure:
...
I. Reassessment of Patients waiting in the lobby: Patients awaiting a(sic) to be taken back to a room will be reassessed as below. Patients may also be re-categorized at any time due to change of the patient condition.
1. Level 1 (Red) acuity: This acuity level should not be waiting in the lobby and should have immediate attention and be expedited to an appropriate room immediately.
2. Level 2 (Orange) acuity: These patients are of high priority to place in an Emergency Center bed and will be reassessed every hour and vital signs will be rechecked every hour or more frequently as needed. Consider up triage if any vital sign or pain scale increases.
3. Level 3 (Yellow) acuity: These patients will be reassessed every two hours and vital signs will be rechecked every two hours or more frequently as needed. Consider up triage if any vital sign or pain scale increases.
4. Level 4(Blue) and Level 5(Green)acuity: These patients are those that only require one or no resources and can wait for several hours. These Patients will be reassessed every two hours and vital signs will be rechecked every four hours or more frequently as needed. Consider up triage if any vital sign or pain scale increases."

The above was confirmed in an interview with the Chief Nursing Officer, the VP of Quality and the Accreditation Manager on the evening of 11-7-17.