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Based on document review, record review, and staff interview, it was determined that the facility failed to meet the emergency needs of patients in accordance with acceptable standards of practice by failing to monitor patient vital signs consistent with facility policy and procedure.

Based on document review, record review, and staff interview, it was determined that the facility failed to monitor patient vital signs consistent with facility policy and procedure in twelve (12) out of twenty (20) patients, patients #2, 4, 5, 6, 7, 11, 12, 13, 14, 15, 16, and 19.

Findings include:

Review of facility policy "Triage Guidelines" last reviewed May 9, 2022, read in pertinent part "Purpose: To rapidly collect relevant subjective and objective data so that the triaging nurse can assign a patient an accurate acuity rating in order to sort injured and ill patients into categories of acuity and prioritization based on urgency of their medical and psychological needs ... Definitions: 1. ESI- Emergency Index Tool: A research -Based Triage Tool ..."

Review of facility policy "Vital Signs and Reassessment Guidelines" last reviewed May 9, 2022, read in pertinent part "Purpose: To establish a clinical Baseline for patient presenting to the emergency department and a guideline for ongoing assessments to detect clinical changes or clinical responses to treatment modalities. Policy: Vital signs on presentation of the patient should be performed and documented in the Epic (Electronic medical record system) as soon as possible and reassessed no longer than the recommended interval by ESI (emergency Severity Index) score or as patients clinical condition warrants for the detection of hemodynamic or therapeutic changes ... Procedure: ... 2. Reassess Vital signs as clinically indicated or no less than: a. ESI Level 1 [one] and 2 [two] -Every hour ... b. ESI Level 3 [three]- Every 2 [two] hours c. ESI Level 4 [four] and 5 [five] - Every 4 [four] hours 3. Discharge vital signs: Assess 30 [thirty] min [minutes] Prior to discharge or patient leaving the unit for admission or another setting ..."

Review was conducted of the medical record for patient #2. The patient presented to the facility on 07/14/22 at 3:40 AM with a chief complaint of abdominal pain and nausea. The patient was assigned an ESI (Emergency Severity Index) of 4 (four). The patient's vital signs were taken at 3:44 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 6:31 AM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #4. The patient presented to the facility on 07/14/22 at 7:28 AM with a chief complaint of pelvic pain and vaginal bleeding. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 7:39 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 9:45 AM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #5. The patient presented to the facility on 07/14/22 at 9:36 AM with a chief complaint of epigastric pain. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 9:41 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 11:35 AM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #6. The patient presented to the facility on 07/14/22 at 11:22 AM with a chief complaint of pelvic pain and vaginal bleeding. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 11:39 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 3:09 PM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #7. The patient presented to the facility on 07/14/22 at 12:30 PM with a chief complaint of vaginal bleeding. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 1:27 PM. No further assessment of vital signs was noted in the ED medical record. The patient was transferred to the Operating Room for surgery at 6:00 PM. The medical record lacks evidence that the patient's vital signs were re-assessed at the appropriate interval associated with assigned ESI, or thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #11. The patient presented to the facility on 03/20/23 at 5:09 AM with a chief complaint of vaginal bleeding. The patient was assigned an ESI of 4 (four). The patient's vital signs were taken at 5:19 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 8:00 AM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #12. The patient presented to the facility on 03/20/23 at 7:55 AM with a chief complaint of vaginal bleeding. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 7:57 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 10:03 AM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #13. The patient presented to the facility on 03/20/23 at 10:25 AM with a chief complaint of vaginal bleeding. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 10:28 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 1:28 PM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #14. The patient presented to the facility on 03/20/23 at 11:11 AM with a chief complaint of vaginal bleeding and abdominal pain. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 11:19 AM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 3:42 PM. The medical record lacks evidence that the patient's vital signs were re-assessed at the appropriate interval associated with assigned ESI, or thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #15. The patient presented to the facility on 03/21/23 at 10:51 AM with a chief complaint of vaginal bleeding. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 10:55 AM and again at 2:17 PM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 4:59 PM. The medical record lacks evidence that the patient's vital signs were re-assessed at the appropriate interval associated with assigned ESI, or thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #16. The patient presented to the facility on 03/21/23 at 6:56 PM with a chief complaint of vaginal bleeding. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 7:06 PM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 8:44 PM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

Review was conducted of the medical record for patient #19. The patient presented to the facility on 03/24/23 at 12:46 PM with a chief complaint of vaginal bleeding and abdominal and back pain. The patient was assigned an ESI of 3 (three). The patient's vital signs were taken at 12:51 PM. No further assessment of vital signs was noted in the medical record. The patient was discharged home, and left the facility at 4:25 PM. The medical record lacks evidence that the patient's vital signs were re-assessed thirty (30) minutes prior to discharge, in accordance with facility policy.

On 03/28/23 at approximately 8:40 AM, an interview was conducted with Registered Nurse (RN) #2. Regarding reassessments, RN #2 states, "The vitals signs are reassessed depending on the patient's acuity level. The system will "flag" you when it is time for another set. If the patient is hooked up to a continuous monitor, the vital signs will have to be reviewed and validated before they are documented into the medical record. When a patient is discharged, you have to get discharge vitals. I always make sure the vitals are documented before I print off the AVS [after visit summary] for the patient." RN #2 showed this surveyor an example of how the system "flags" when a reassessment is due, and how to validate the vital signs.

On 03/28/23 at approximately 8:45 AM, an interview was conducted with an ED technician. The ED technician explained they can also document vital signs on patients depending on how long the patient has been there, and if asked by a RN.

On 03/28/23 at approximately 8:55 AM, an interview was conducted with RN #3, who was working in the triage area. Regarding reassessment of vitals, RN #3 states, "We reassess the vital signs based on acuity of the patient, usually a level three (3) or four (4) acuity is every three (3) to four (4) hours. A set of discharge vitals would be based on acuity and how long they have been there. We have a tracking board that shows you how long the patient has been in the ED."

An interview was conducted with the Nurse Manager of the ED on 03/28/23 at 10:53 AM. Regarding reassessment of vital signs on patients in the ED, the Nurse Manager states, "We are working on a PI [Performance Improvement] project right now for reassessments and vitals signs. The vital signs do need to be taken thirty (30) minutes prior to discharge. The Epic system does not flag the staff a reminder to take the discharge vitals. We need to make it a habit and part of the process to take the vitals upon discharge."

On 03/28/23 at 4:15 PM, the Regulatory Compliance Coordinator confirmed there were no additional vitals signs documentation found for patients # 2, 4, 5, 6, 7, 11, 12, 13, 14, 15, 16, or 19.