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Based on staff interview and record review, the hospital failed to assure that all medical record entries were complete in accordance with Emergency Department (ED) hospital policies related to Nursing documentation. The deficient practice referred to medical records for 7 of 10 ED Patients in the sample. (Patients # 3,4,5,6,8,9 and 10). Findings include:

Per review of ED patient records during the 2 days of the survey (1/4/16 - 1/5/16), nursing staff documentation was not in accordance with current ED policies and procedures related to required medical record documentation. The records revealed documentation omissions related to 2 ED policies/procedures as well as omissions of descriptions of patient clinical signs and symptoms regarding nursing care provided to Patients #5, #8, #9 and #10.
Policy #1:
Per review, the Triage, Emergency Department policy/procedure, last reviewed 5/2011, III., stated:
"Triage", 6. Vital signs will be obtained and recorded as often as necessary to accurately assess or reassess patient condition.....,
a. Vital signs to include blood pressure, pulse, respiration, pulse oximetry, temperature, pain level.,
(3), If vital signs are not measured and recorded, reason for deferment should be documented on the E.D. T.R.

Per review of a total of 10 ED patient records regarding nursing documentation, nurses documented Vital Signs (VS) at the time of discharge as 'deferred' for Patient's #5, #8, #9 and #10, without documenting the reason for doing so. Additionally, this documentation omission also violated the ED policy/procedure entitled Discharge of Patients, last reviewed 03/2012, as follows:
Policy #2:
II. Procedure: A. Prior to discharge, patients will have:
d. Patients must meet acceptable clinical criteria before discharge.
1) Stable Vital Signs (B/P, P, R, T, SaO2, pain level).
2) No projected acute deterioration in signs or symptoms of current diagnosis or it's treatment.
3) Patient's physical and mental capabilities at baseline status.

For 7 of 10 patients reviewed, nurses failed to document a completed set of Vital Signs at the time of discharge form the ED, thereby failing to show that these patients had stable VS and were at physical and mental baseline status. The survey was conducted to investigate a patient complaint regarding concerns with the care and services received in the ED and the sample of records reviewed focused on patients with head injuries. Specific concerns related to 3 patients are included as follows:

1. Per record review, on 12/26/15 at 00:27 Patient #5 arrived in the ED after sustaining lacerations and abrasions to the forehead and a nasal injury after a possible fall. A nursing progress note stated at 0059, 12/26/15, Patient #5 was administered Haldol IM, 10 mg in the right arm. There was no further documentation regarding the patient's behaviors, why the antipsychotic medication was administered and the patient's response to the medication. However, per review of the physician progress note, Patient #5 was described as having " ....altered mental status: confused combative (slurred speech, appears intoxicated) .....Haldol IM for sedation " . During the 6 hours in the ED, Patient #5 experienced episodes of hypoxia (when the body does not get enough oxygen) while asleep, resulting in a drop in the patient's oxygen level. Eventually, Patient #5's condition stabilized and it was determined s/he could be discharged. The nursing note stated: "Vital signs/pain levels deferred." Nursing staff failed to document justification why the patient was not reassessed, per policy, and to assure prior to discharge the patient's vital signs and pain level were stable, given the patient's head injury and hypoxic episodes.

2. Per record review, on 10/24/15 at 10:03 Patient #8 arrived in the ED with a chief complaint of a head injury, having been hit by the tailgate of a truck. Per MD progress note, Patient #8 " ...sustained a blow to the head, complains of neck pain and was dazed. No loss of consciousness or seizure .... has some nausea " . The clinical impression was Patient #8 had sustained a concussion. The nursing progress note stated " Vital signs deferred " . No reason was documented stating why the vital signs, including pain level were deferred.

3. Per record review, on 12/7/15 at 12:43 Patient #10 arrived in the ED after sustaining a head injury reporting s/he " ...went under low door and did not duck enough " . The 67 year old patient complained of a headache and had sustained a blunt force laceration. It was documented that the patient's B/P was 'out of range' at 150/108 at the time of admission to the ED. Although the elevated B/P was highlighted in red in the patient ' s vital signs log, no further monitoring of Patient #10's vital signs or pain level were obtained at the time of discharge from the ED.

4. Per record review, Patient #9 had sustained a blow to the head while involved in a sporting event. The injury had happened 2 days prior to the ED visit (11/11/15 at 1842) and the patient was complaining of increased symptoms including double vision, amnesia, headache, nausea and increased forgetfulness, per physician and nursing notes. The patient had been to an urgent care center earlier in the day, and due to ongoing concerns, went to the ED for further evaluation. Medications for pain and nausea were administered and a CT scan was done. The patient was discharged from the ED at 2055 and all VS were documented as 'deferred', with no reason documented in the medical record by the nurse.

The nursing documentation omissions, in violation of ED nursing policy/procedures, were confirmed during interviews with the Clinical Director of ED Services on 1/4/16 at 4:15 PM and on 1/5/16 at 1:10 PM.