HospitalInspections.org

Based on medical record review, review of the facility's policies/procedures, and staff interview, the facility failed to ensure that policies and procedures governing the medical and nursing care provided in the emergency department were established, specifically the ongoing assessment and collection of vital signs of patients that remained in the emergency department for extended periods of time. This failure had the potential to result in negative patient outcomes.

The findings were:

A review of the facility's policies and procedures on 10/25/2011, revealed that the facility did not have an Emergency Department specific policy that listed the expectations for the frequency for nurses in the department to document assessments or the collection of vital signs on patients.

An interview with the facility's Director of Emergency Services conducted on 10/25/2011 at approximately 11:00 a.m., revealed that the Emergency Department did not have a specific policy that addressed the frequency of nursing assessments or of the collection of vital signs of patients. S/he stated that the department's staff was to take into account the patient's triage level at that particular time and that if a patient was not being admitted to the hospital, that the only expectation would be that an assessment and vital signs would be done upon discharge of the patient. S/he further indicated that the facility's triage policy was the closest policy that would direct nursing staff to an expectation of reassessment of patients as well as recollection of vital signs.

A review of the facility's policy titled "Triage" last revised June 2010, revealed the following, in pertinent part:
"...D. Reassessment will occur as chief complaint/condition warrants. Reassessment will include patient progress with repeat vital signs only if an abnormality exists, or treatment/condition warrants. Triage Registered Nurse (RN) will reassess any patient that has waited over two hours for an ED room..."

An interview with the facility's Chief Nursing Officer conducted on 10/25/2011 at approximately 11:35 a.m., revealed that the hospital had a policy that provided an expectation for patients that were admitted to the hospital as well as those patients that remained in the Emergency Department after admission orders were written. However, the policy did not provide expectations for patients that remained in the Emergency Department that were awaiting placement at another facility (i.e. Psychiatric Hospital). S/he stated that s/he would expect that nurses would then rely on their expertise and that it would be reasonable for a reassessment and vital signs to be performed once a shift in that circumstance.

A review of the facility's policy titled "Multi-disciplinary Patient Assessment and Reassessment of Patients," last revised March 2011, revealed the following, in pertinent parts:
"I. Purpose:
A: The goal of assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs. Patient needs must be reassessed throughout the course of care, treatment, and services...
C. The depth and frequency of assessment depends on a number of factors, including the patient's needs, program goals, and the care, treatment, and services provided. Assessment activities may vary between settings, as defined by facility standards...
II. Policy...
F. Assessment and Reassessment data is shared among disciplines to enhance the continuity of care and demonstrates that this is a multidisciplinary process.
1. All patients will be assessed by an RN a minimum of every shift and documented.
2. The timing, scope and intensity of reassessment are based on the patient's diagnosis, acuity, desire for care, response to any previous care, and change in condition and/or diagnosis..."

A review of Emergency Department records, conducted 10/25/2011, revealed that patients that had remained in the Emergency Department greater than 24 hours had inconsistent reassessment periods.

Sample patient #5 was an adult patient that presented to the Emergency Department on 7/12/2011 at approximately 7:12 p.m. with a chief complaint of needing a psychological evaluation. A review of the computer documentation of vital signs collection by nursing staff revealed that the period of time between collection of the patient's vital signs ranged from approximately two hours to as long as a period of 12.2 hours (between 7/14/2011 at 9:53 a.m. through 7/14/2011 at 10:05 p.m.). The patient was transferred to an acute care psychiatric hospital on 7/16/2011.

Sample patient #8 was an adult patient that presented to the Emergency Department on 5/14/2011 at approximately 4:46 p.m. with symptoms of schizophrenia. A review of the computer documentation of vital signs collection by nursing staff revealed that the period of time between collection of the patient's vital signs ranged from approximately 15 minutes to as long as a period of 11.7 hours (between 5/15/2011 at 8:10 p.m. through 5/16/2011 at 7:56 a.m.). The patient was transferred to an acute care psychiatric hospital on 5/17/2011.

Sample patient #14 was an adult patient that presented to the Emergency Department on 8/16/2011 at approximately 1:25 p.m. with symptoms of bipolar disorder. A review of the computer documentation of vital signs collection by nursing staff revealed that the period of time between collection of the patient's vital signs ranged from approximately one hour to as long as a period of six hours. The patient was transferred to an acute care psychiatric hospital on 8/17/2011.

Sample patient #16 was an adult patient that presented to the Emergency Department on 10/12/2011 at approximately 12:55 a.m. with hallucinations. A review of the computer documentation of vital signs collection by nursing staff revealed that the period of time between collection of the patient's vital signs ranged from approximately 7.4 hours to as long as a period of 14.7 hours. The patient was transferred to an acute care psychiatric hospital on 10/13/2011.