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Based on interview, policy review and review of 1 of 1 medical record for a patient (#1) who presented to the ED after a seizure, it was determined that the hospital failed to ensure the patient's right to receive care in a safe setting, including full implementation of hospital policies and procedures for monitoring the patient's condition, as required.

Findings include:

1. Review of the policy titled, "Emergency Department: Vital Signs Measurement," effective 08/31/2011, reflected the following internal requirements: Vital signs in the emergency department will be collected and charted following the standards outlined in this policy. Vital signs are defined as pulse, respiratory rate, blood pressure, oxygen saturation level and temperature...[Emergency Severity Index] [triage] level 3 patients in the emergency department will have vital signs recorded at a minimum of 2-hour intervals...Abnormal vital signs will be rechecked within 30 minutes...The policy included a table of normal vital signs for adults. The normal range for blood pressure readings was 100-150 (systolic) and 60-100 (diastolic).

2. Review of the protocol titled, "Alcohol Withdrawal Protocol -- Adults Acute Care Units," dated online 03/23/2010, identified the following internal requirements: Score patient with CIWA-Ar scale upon initiation of order set...Medicate and reassess as follows..." The protocol included a table of CIWA-Ar scoring scales with corresponding medication dosages, reassessment timeframes, and licensed independent practitioner notification directions to be completed, based on the CIWA-Ar score.

3. A phone interview was conducted with Employee A, an ED nurse, on 09/11/2012 at 1300. Employee A stated that Patient #1 was a triage level 3, and the hospital policy for checking vital signs for patients who were a triage level 3, was usually every 2 hours. He/she reviewed Patient #1's medical record and stated vital signs were checked at 1200, 1740 and 1900. The nurse was asked why vital signs were not rechecked every 2 hours, between 1200 and 1740, and he/she stated, "Probably because we were busy."

4. Patient record #1: Review of nurse notes dated, 06/06/2012 at 1151, reflected the patient arrived at the ED by ambulance after having a possible alcohol withdrawal seizure. Review of nurse flowsheets dated, 06/06/2012 at 1155, reflected the patient's condition was urgent and his/her blood pressure reading was 153/112 mm/Hg. The systolic and diastolic readings were outside the normal range per the policy above. Review of the record reflected vital signs were not recorded again until 06/06/2012 at 1740, nearly 6 hours later.

Review of ED physician notes dated, 06/06/2012 at 1301, with an addendum dated, 06/06/2012 at 1901, reflected the patient had a seizure and slid off the bed on 06/06/2012 at 1648 (nearly 5 hours after the vital signs were checked at 1155). The physician notes reflected the patient had been signed out to the incoming ED team at shift change, and the plan was to repeat vital signs to evaluate the patient for delirium tremens (a severe form of alcohol withdrawal). However, the physician notes further reflected that the vital signs were not done for several hours as planned.

Review of ED physician notes dated, 06/06/2012 at 1718, reflected the patient was found to have bilateral humeral head (shoulder) fractures likely the result of the seizure.

Review of nurse flowsheets dated, 06/06/2012 at 1740, reflected the patient's blood pressure reading was 146/101 mm/Hg. The diastolic reading was outside the normal range. However, review of the record reflected vital signs were not rechecked until 06/06/2012 at 1902, over an hour later.

Review of nurse flowsheets dated, 06/06/2012 at 1922, reflected the patient's blood pressure reading had increased and was 169/119 mm/Hg. The systolic and diastolic readings were outside the normal range. Review of the record reflected vital signs were not rechecked until 06/06/2012 at 2000, 38 minutes later.

Review of nurse flowsheets dated, 06/06/2012 at 2030, reflected the patient's blood pressure reading was 165/119 mm/Hg. The systolic and diastolic readings were outside the normal range. Review of the record reflected vital signs were not rechecked until 06/06/2012 at 2135.

Review of physician orders dated, 06/06/2012 at 1421, reflected that an Alcohol Withdrawal Protocol (CIWA-Ar) was ordered. Review of ED physician notes dated, 06/06/2012 at 1301, with an addendum dated, 06/06/2012 at 1901, reflected that a CIWA protocol was started at 1423. However, review of the record reflected a CIWA-Ar scale was not completed until 06/06/2012 at 1832, more than 4 hours after it was ordered by the physician. Review of the record reflected that vital signs and the CIWA-Ar protocol were not conducted in accordance with hospital policies, procedures and physician orders. Therefore, the patient's condition was not monitored appropriately in order to ensure his/her right to receive care in a safe setting.

Based on interview, policy review, and review of documentation, it was determined the hospital failed to ensure patients were fully informed of their visitation rights, including accurate visitation hours, in accordance with the hospital policy.

Findings include:

1. Review of the policy titled, "Patient Visitation," effective 03/07/2012, reflected, "...There are no specific hours for visitation in the hospital or clinics."

2. Review of the patient admission pamphlet titled, "Welcome to OHSU Hospital," dated, 06/2011, reflected, "Hours for visiting...Visiting hours are between 11 a.m. and 8 p.m." The pamphlet was not fully developed to accurately reflect the visitation hours, as defined in the hospital visitation policy.

3. During an interview with the Director of Patient Relations on 08/31/2012 at 1340, he/she reviewed the patient admission pamphlet and visitation policy. The director acknowledged that patients were given the admission pamphlet to inform them of their visitation rights, including the hospital visitation hours. The director acknowledged that the visitation hours in the admission pamphlet did not accurately reflect the hospital visitation policy, and needed to be corrected to reflect the actual visitation hours.

4. These findings were reviewed with the Regulatory Affairs Coordinator on 08/31/2012 at 1345.