HospitalInspections.org

Based on record review and interview, the facility failed to ensure that 2 of 10 sampled Emergency Department (ED) were assessed on an hourly basis per facility policy ( Patient ID # 3, # 7)

Findings include:

TX # 00216630

Patient # 7 :

Review of the clinical record of Patient # 7 revealed he was a 71 year old male who presented to the ED via ambulance on 0-13-15 with complaints of back pain.

Further review of Patient # 7's ED record revealed the following timeframe:

1439 hours : Arrived in ED
1457 hours: Triage exam completed [Emergency Severity Index (ESI) Level 4]
2310 hours: Medical Screening Exam completed
2332 hours: Discharged home

[Total time in ER was approximately 9 hours]

The record contained documentation that Patient # 7's vital signs were measured only twice during his time in the ER:

1458 hours: blood pressure was 175/92
1710 hours: blood pressure was 204/104

There were no medical interventions or follow-up blood pressure measurements documented.

Interview on 07-07-15 at 11 a.m. with ED Director # 4 she stated the policy was that all patients in the lobby and in the treatment rooms were assessed hourly via "hourly rounds, "which included vital signs. She said she recently implemented an "ER Rounding Log" in order to ensure the rounds were being done. She reviewed Patient # 7's record and acknowledged there were only 2 sets of vital signs in 9 hours. She said that many times, Patient # 7 would be outside and also refused; but this was not documented.

Patient # 3:

Review of Patient # 3's clinical record revealed she was a 24 year old female who presented to the ED on 07-06-15 at 1612 hours with a diagnosis of " closed head injury." Timeframes recorded for Patient # 3:

1612 hours: Triaged
1620 hours: medical screening exam
1810 hours: vital signs
2018 hours: vital signs
2136 hours: vital signs
2138 hours: discharged home

RN # 7 was unable to locate documentation of the hourly nursing assessment/vital signs for 1900 hours.

Review of facility policy titled " Rounding in The Lobby & the Emergency Department," dated February 2011, read: 1. All patients waiting in the lobby will be rounded on approximately every hour. During rounding, they will be assessed for the following: a.) changes in their condition b.) vital signs c.) ESI level d.) inform patients of the delay...4. patients in rooms will be rounded on approximately every hours to check on patient's condition...