HospitalInspections.org

Based on interview and clinical record review, the facility failed to ensure one of ten sampled patient's (Patient #7's) medical records included all vital signs and nursing assessments. The sample size was 10 patients.

Findings:

The clinical record review for Patient 7 was completed on 06/29/10. The clinical record review revealed a nursing note dated 01/10/10 at 4:08 P.M. that stated the patient arrived via emergency services unresponsive to stimuli with frothy "sputum/emesis" draining from mouth. The note stated the patient did not have any gagging. The note stated there was a nasopharyngeal airway in place and Patient 7 was suctioned for scant amount of yellowish secretions.

The clinical record review revealed a physician's order set dated 01/10/10 at 6:15 P.M. to admit the patient for cardiac monitoring for a diagnosis of urinary tract infection and change in mental status. The order set stated to take vital signs every four hours, and provide five liters oxygen as needed for dyspnea, cyanosis, and persistent pain.

The clinical record review revealed Patient 7's last vital signs taken in the emergency department at 01/10/10 at 8:00 P.M. were respirations of 37 breaths per minute, heart rate of 90 beats per minute, and oxygen saturation of 93 percent (blood pressure and supplemental oxygen levels are not recorded).

A nursing note dated 01/10/20 at 8:15 P.M. indicated the patient had been transferred to and arrived at the hospital's intensive care unit. The clinical record review revealed at that time Patient 7's vital signs were: temperature of 101.5 degrees Fahrenheit, heart rate of 86 beats per minute, respirations of 28 breaths per minute, and oxygen saturation of 93 percent with oxygen at five liters by nasal cannula. (Blood pressure not recorded).

The clinical record review revealed vital signs recorded on a rhythm strip recorded on 01/10/10 at 8:22 P.M. The vital signs were respirations of 42 breaths per minute and a pulse of 87 beats per minute. No temperature, blood pressure or oxygen saturation was recorded.

The clinical record review revealed a nursing note dated 01/10/10 at 10:00 P.M. that stated, "Vitals obtained" and Patient 7's oxygen levels were 93 percent of 5 liters of supplemental oxygen.

The surveyor was unable to locate the aforementioned vital signs in the 01/10/10 at 10:00 P.M. nursing note or a comprehensive nursing assessment

The clinical record review revealed vital signs recorded on a rhythm strip recorded on 01/11/10 at 12:07 A.M. that stated the patient had a heart rate of 83 beats per minute, respirations of 34 breaths per minute, and an oxygen saturation of 96 percent (any supplemental oxygen was not recorded).

On 06/29/10 at 2:00 P.M. in an interview, Staff E stated there was nursing documentation missing from the clinical record, and that that documentation included the above vital signs and respiratory assessment.