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Based on record review, interview and policy review, the facility failed to ensure that staff completed vital signs as required during a patient's stay in the emergency department. This affected five (Patients #2, #3, #4, #5 and #6) of ten patients reviewed. This had the potential to affect all patients receiving care in the emergency department. The census was 80.

See A1104.

Based on record review, interview and policy review, the facility failed to ensure that staff completed vital signs as required during a patient's stay in the emergency department. This affected five (Patients #2, #3, #4, #5 and #6) of ten patients reviewed. This had the potential to affect all patients receiving care in the emergency department. The census was 80.

Findings include:

1. Record review revealed Patient #2 came to the emergency department (ED) on 09/08/23 at 2:10 PM with complaints of vaginal bleeding for the past two months after a chemical abortion. Triage staff assigned an emergency severity index (ESI) score of three. Vital signs were completed at 2:14 PM as follows: temperature 96.8 degrees Fahrenheit (F); blood pressure, 110/87; heart rate 73 beats per minute; respirations 18 breaths per minute; and oxygen saturation of 99 percent on room air.

Review of the ED physician notes documented they consulted with a obstetrical physician who believed this patient was still miscarrying. Cytotec (prostaglandin) 600 milligrams (mg) was given at 6:34 PM. Patient #2 was discharged home at 6:32 PM with discharge instructions for miscarriage. No vital signs had been obtained since being triaged at 2:14 PM.

2. Record review revealed Patient #3 was admitted to the ED on 09/19/23 at 3:54 PM with complaints of having a miscarriage earlier in the day and continued vaginal bleeding. Triage was completed with an assigned ESI score of three.

Patient #3 was taken to an exam room at 5:37 PM. Vital signs were completed at 5:40 PM as follows: temperature 97.7 degrees F; heart rate 106 beats per minute; blood pressure 137/94; respirations 22 breaths per minute; and oxygen saturation of 100 percent on room air. Vital signs were not obtained again until 9:35 PM. Patient #3's blood pressure was 104/44; heart rate 83 beats per minute; and an oxygen saturation of 98 percent.

3. Record review revealed Patient #4 came to the emergency department triage on 11/06/23 at 6:41 PM with complaints of vaginal bleeding. Vital signs were completed at 6:43 PM. Blood pressure was 171/86; heart rate 98 beats per minute; respirations 16 breaths per minute; temperature 97 degrees F; and oxygen saturaiton of 110 percent. Triage assigned an ESI score of three.

A pelvic ultrasound was completed with results listed as no acute findings. Patient #4 discharged home on 11/06/23 at 11:30 PM.

There were no vital signs documented after triage.

4. Record review revealed Patient #5 came to the ED on 9/22/23 at 11:32 PM with complaints of new vaginal bleeding post hysterectomy two weeks prior. Vital signs were completed at 11:33 PM. Temperature was 97.6 degrees F, heart rate 73 beats per minute; respirations 15 breaths per minute; blood pressure 136/88; and an oxygen saturation of 100 percent. A CT scan was completed with no localized collection of fluid or hematoma.

Patient #5 was discharged home at 4:30 AM.

There were no vital signs documented after triage.


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5. Record reviewe revealed Patient #6 arrived at the ED on 06/06/23at 11:41 AM and was triaged at 11:43 AM for chief complaint of right lower quadrant pain. Patient #6 was assigned an ESI of three.

Review of the vital signs at 11:41 AM resulted as follows: temperature 98.5 F, heart rate 109 beats per minute; respiratons 16 breaths per minute; blood pressure 141/102; and oxygen saturation 100 percent on room air.

Patient #6 was discharged to home at 4:30 PM. No additional vital signs were documented during the visit or prior to discharge.

On 06/07/23 at 5:52 PM, Patient #6 arrived back to the ED and triaged at 5:52 PM for chief complaint of abdominal pain, nausea, and diarrhea. Patient #6 was assigned an ESI of three. Vital signs were temperature 97.4 degrees F; heart rate 105 beats per minute; respirations 18 beraths pre minute; blood pressure 154/110; and oxygen saturation 100 percent on room air.

Patient #6 was discharged to home at 8:07 PM.

No other vital signs were documented during the ED visit or prior to discharge.

During an interview on 02/27/24 at 2:11 PM, Staff A confirmed vital assessments had not been documented for the above patienst every two hours per hospital policy.

Review of the facility policy titled "Documentation Guidelines for Emergency Department", undated, revealed vital signs based on ESI level 3 should be documented every 120 minutes, change in condition, as ordered, prior to medication administration when indicated (narcotics, sedatives, medications that may affect vital signs), and at disposition.