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Based on record review and interviews, the facility failed to ensure the nursing staff monitored, assessed and reassessed patients according to physician orders and the unit-specific policy. The failure was identified in 1 of 5 medical records reviewed (Patient #1).

Findings include:

Facility policy:

The policy, Assessment/Reassessment read, the assessment framework will be structured around two components: initial screening/assessment and reassessment of all patients as appropriate to the clinical discipline and individual patient condition. Information generated via the patient's assessment/reassessment will be documented in the patient's electronic medical record (EMR). The reassessments are ongoing and occur at designated intervals during the patient's treatment to determine the response to and the effectiveness of care/interventions. According to the Clinical Assessment/Reassessment Guidelines, reassessments on the medical telemetry floor should be focused reassessments every shift, and as the patient's condition warrants. Documentation should occur within 2 hours. Performing an initial assessment included, but not limited to, physical assessments and vital signs. Reassessments were ongoing and triggered by pertinent data to include, but not limited to, "acute change in the patient condition and/or change in diagnosis".

1. The facility failed to ensure the nursing staff conducted vital sign monitoring and physical assessments/reassessments according to the physician orders and the unit-specific policy.

a. A record review was conducted for Patient #1 who was admitted as an inpatient on 8/26/19 due to complaints of abdominal pain, nausea/vomiting, and increased work of breathing. On the morning of 9/3/19, the patient was transferred to the intensive care unit (ICU) due to worsened clinical condition and physical decompensation.

According to a physician order entered on 8/27/19 at 1:22 a.m., nurses were to notify the provider for the following vital signs: Temperature greater than 38.3 C, heart rate below 50, or a systolic blood pressure less than 90

Review of the medical record documentation from 9/1/19-9/3/19 found gaps in nursing physical assessments/reassessments and vital sign monitoring. The review also found a lack of evidence the provider was notified of changes in the patient's condition per the 8/27/19 order.

i. For example, on 9/1/19 there was no documented evidence the patient's primary day shift nurse conducted and documented a head to toe assessment during the shift. The lack of assessment was non-compliant to the unit-based policy which stated assessments should occur at least once a shift.

ii. On 9/2/19 at 12:43 p.m., documentation of Patient #1's vital signs found abnormal results with no timely reassessment of vitals or physician notification as needed. Patient #1's blood pressure was documented by a registered nurse (RN #1) as 84/54 with a heart rate of 32, both critically low.

According to the record, the patient's vital signs weren't rechecked until 9/2/19 at 4:18 p.m., three and a half hours later. Though the blood pressure and heart rate were found to be within normal limits, the patient's temperature was 38.4 C and indicated the presence of a fever. However, there was no documented evidence the primary nurse reassessed, treated, or notified the provider of the abnormal vital sign value in a timely manner.

iii. Further review of Patient #1's medical record identified another gap in the patient's head to toe assessment. On 9/3/19 at 12:20 a.m., the nurse reported to the physician that Patient #1's medical condition had worsened and requested the patient be transferred to the ICU for closer monitoring. Review of the nurse's documentation found no evidence of a documented head to toe assessment during their shift. Therefore, the record review was unable to identify the patient's baseline physical assessment at the start of that shift.

b. On 2/19/20 at 11:43 a.m., an interview was conducted with RN #1. RN #1 stated the medical surgical (med/surg) nursing staff were expected to conduct a head to toe assessment at the beginning of their shift to establish the patient's baseline medical status. RN #1 stated a reassessment was warranted if the patient experienced a change in medical condition. RN #1 stated vital signs should also be reassessed if an abnormal finding was identified. RN #1 stated all assessments/reassessments, interventions, or notifications to the physician regarding the patient's change in clinical condition must be documented in the medical record.

c. On 2/20/20 at 1:09 p.m., an interview was conducted with RN #2 who was staffed on the med/surg unit as a charge nurse. According to the interview, the certified nursing assistants (CNA) typically collected patient vital signs on the med/surg unit, but the charge nurses could assist as needed. RN #2 stated vital signs were collected on a mobile machine and electronically transferred to the patient's EMR. If an abnormal vital sign was found, they should be immediately reported to the patient's primary nurse. RN #2 stated this was important because the primary nurse was responsible for knowing the patient's vital signs, determining if normal or abnormal, and ensuring the vital signs were documented in the EMR.

i. RN #2 reviewed the medical record for Patient #1 and confirmed she had collected Patient #1's vital signs on 9/2/19 at 12:43 p.m. RN #2 confirmed the vital signs were abnormal, and if accurate, required immediate medical intervention. RN #2 stated she could not remember the patient, and the documentation may not be accurate, but it was the responsibility of nursing staff to ensure accurate vitals were documented in the medical record. RN #2 stated the documented vital signs would require an immediate reassessment of the patient and vital signs, notification to the primary nurse, and treatment or notification to the physician if the patient was symptomatic. RN #2 stated if the patient had an irregular cardiac rhythm, or issues with the pulse oximeter (a non-invasive device that measured the oxygen saturation of a person's blood as well as their heart rate) cord on the patient's finger, an inaccurate heart rate value could have been recorded in the EMR. However, she reinforced it was ultimately the responsibility of the nurse to assess and reassess patients as needed, and ensure the accuracy of nursing assessments/reassessments recorded in the EMR.

d. On 2/24/20 at 10:00 a.m., an interview was conducted with the med/surg unit manager (Manager #3). Manager #3 stated nurses were expected to obtain vital signs and physical assessments/reassessments according to the unit's policy and the physician orders. Manager #3 reviewed the record for Patient #1 and confirmed the gaps in nursing physical assessments and vital sign reassessments. Manager #3 stated abnormal physical findings and vital signs must be reassessed and treated, or the physician notified as needed.

Manager #3 stated the facility had not previously identified this concern, or conducted any process improvement activities to address gaps in nursing vital sign monitoring or physical assessments/reassessments.