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Based on medical record review, document review and interviews, the facility staff failed to monitor vital signs in accordance with their policy and procedure for 3 (three) of 6 (six) patients included in the survey sample. Patient #2, Patient #4 and Patient #6.

The findings included:

A comprehensive review of medical records was conducted on 1/17 and 1/18/24 with the assistance of Staff Members (SM) #4, #5, and #6. Review of the medical record for Patient #2 (an infant) evidenced the following:

12/23/23 10:39 PM - Patient #2 arrived to ER presenting with nasal congestion and tachycardia. The medical record documented following times and types of vital signs collected:
10:42 PM - vital signs at triage: heart rate 147, respiratory rate 38, O2 saturation 96%. temperature 98.4 °F: Level 4 acuity
00:10 AM - pulse 167. O2 saturation 100%
4:07 AM - pulse 166, respiratory rate 33, O2 saturation 89%
4:09 AM - patient discharged home
As much as 3 hours 53 minutes elapsed between the collection of vital signs.

Review of the medical record for Patient #4 (an infant) evidenced the following:

12/22/23 2:38 PM - Patient #4 arrived to ER presenting with fever, cough and difficulty breathing. The medical record documented following times and types of vital signs collected:
2:52 PM - vital signs at triage: heart rate 157, respiratory rate 48, O2 saturation 97% on 0.5 L nasal cannula, temperature 101.6 °F: Level 2 acuity
6:19 PM - blood pressure 116/63, wt. 4.182 kg
8:00 PM - respiratory rate 40
8:11 PM - respiratory rate 40
8:44 PM - respiratory rate 46, heart rate 155, O2 saturation 93%, temperature 102.6 °F:
11:21 PM - respiratory rate 39, heart rate 145 patient transferred to higher level of care, left hospital
As much as 5 hours and 52 minutes elapsed between collection of pertinent vital signs.

Review of the medical record for Patient #6 (adult geriatric) evidenced the following:

11/14/23 12:33 PM - Patient #6 arrived to ER presenting with altered mental status. The medical record documented following times and types of vital signs collected:
12:42 PM - vital signs at triage: heart rate 67, blood pressure 126/78, respiratory rate 17, O2 saturation 93%, temperature 97.6 °F: Level 3 acuity
4:38 PM - heart rate 70, blood pressure 139/79, respiratory rate 19, O2 saturation 98%, temperature 97.1 °F
8:41 PM - heart rate 66, blood pressure 173/90, respiratory rate 19, O2 saturation 97%
11:47 PM - heart rate 69, blood pressure 187/92, respiratory rate 14, O2 saturation 94%
4:07 AM - heart rate 72, blood pressure 180/94, respiratory rate 16, O2 saturation 92%
4:11 AM - patient discharged
As much as 4 hours and 20 minutes elapsed between collection of pertinent vital signs.

Facility policy "Nursing Assessment and Documentation" effective 11-2022 provided the following guidelines for Emergency Department Nursing Assessments: "Complete a focused assessment upon admission (all pertinent systems and psychosocial history related to ED visit) or more frequently as the patient condition dictates. Vital signs: Every 2 hours or per Provider order."

When asked what the expectation is for assessments and collection of vital signs for ED patients, SM #4 replied that assessments are in triage and as needed based or the patient condition or physician orders but vital signs are to be taken every 2 hours. During the record reviews, SM #4, #5 and #6 were given the opportunity to locate additional documentation for each of the three patients. They were unable to present any additional evidence.

The surveyor shared the findings and concerns related to the failure to monitor patients according to policy with the facility's leaders at the exit conference on 1/18/24 at 3:30 PM.