HospitalInspections.org

Based on interview and record review the facility failed to assess patient vital signs in one (1) of one (1) patient file (ID# 1) as accordingly to facility policy in the phase II recovery area.

Findings include:

Interview with staff nurse (ID# 63) on 11/15/2016 at 10:49 AM revealed the following:
"There are times when patients meet discharge criteria, but do not want to leave the facility. If this occurs, they are allowed to " sleep it off " in the recliner in the Phase II stepson recovery area. If the discharge criteria have been met, and discharge instructions have been given, there is no longer a need to monitor the vital signs".

Interview with staff nurse (ID# 59) on 11/15/2016 at 10:15 AM revealed that vital signs are taken upon the patient being received in the Phase II area. That may be the only vital sign that is taken, unless the patient is here for more than an hour.



Review of the facility policy titled: Documentation, Perianesthesia Services dated 6/16/2016 revealed the following information:

PACU Phase II Documentation
I-View Tab
1. Perioperative Flow Sheet Record: Record Every 30 minutes:
a. Vital Signs
b. Oxygen Therapy (as applicable)
c. CVP (as applicable)
d. Arterial Line (as applicable)
e. Pain Assessment
f. Aldrete Level
g. Respiratory/ Breath Sounds
h. Ventilator/BiPAP (as applicable)
i. Incision/ Wound Care
j. Neuro/Motor/Sensory (as applicable)
k. Pupils (as applicable)
l. Pulses (as applicable)
m. Capillary Refill (as applicable)