HospitalInspections.org

Based on the facility policy review, medical record review and interview, the facility failed to ensure vital signs were monitored according to physician orders or facility policy for 1 of 3 (Patient #2) sampled patients reviewed for vital sign monitoring.

The findings included:

1. Review of the facility policy titled, "Standards of Practice Guidelines for Patient Care Units." dated 4/2017 and last revised 11/2021, revealed, "...The following standards of practice are provided to patients...who are being cared for on any of the Nursing units...Documentation of these standards in process interventions by the registered nurse confirms that these standards of practice have been met...DOCUMENTATION...Document Vital Signs per unit standard or as ordered including, Temperature, Heart Rate, blood pressure and level of consciousness...Medical-Surgical Unit every 4 hours..."

2. Review of the medical record Patient #2 was admitted on 8/18/2023 with diagnoses of Abdominal Pain, Nausea and Vomiting.

A physician's order dated 8/18/2023 at 9:10 AM, revealed "...Vital Sign Parameter...Notify HR [Heart Rate] below: 50..."

Review of the CLINICAL DOCUMENTATION RECORD revealed on 8/18/2023 at 9:19 AM, vital signs were as follows: blood pressure (BP) 170/90, pulse 47, respiratory rate 18, SPO2% (oxygen saturation, which is a measurement of the amount of oxygen in the arterial blood)100, room air.

Review of the CLINICAL DOCUMENTATION RECORD revealed on 8/18/2023 at 9:41 PM, vital signs were as follows: BP 141/87, pulse 54, respiratory rate 16, SPO2% 100 room air.

There was no documentation the physician was notified of Patient #2's heart rate of 47 (less that the 50 parameter in the physician's order). There was no documentation Patient #2's vital signs were taken from 8/18/2023 at 9:19 AM to 8/18/2023 at 9:41 AM (12 hours 22 minutes, instead of every 4 hours per policy).

During an interview on 5/1/2024 at 12:24 PM, the Vice President of Quality and Risk Management stated staff were supposed to take patients' vital signs every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. The Vice President of Quality and Risk Management stated, "We are missing the 12 noon and 4 PM [for Resident #2]."

During an interview on 5/1/2024 at 12:43 PM, the the Assistant Chief Nursing Officer confirmed Patient #2 had orders to notify the physician if the heart rate was less than 50.

During an interview on 5/1/2024 at 1:10 PM, the Vice President of Quality and Risk Management stated, "There is an opportunity for improvement on the heart rate, it was missed."