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LEHIGH VALLEY HOSPITAL - POCONO
EMERGENCY SERVICES POLICIES
Tag No.: A1104
Based on review of the American Heart Association document, facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure reassessment of an Emergency Room patient was completed within two hours for a Level 3 patient for one of 18 medical records reviewed (MR1).
Findings include:
Review on February 24, 2015 of the facility's policy "Standards of Care: Emergency Department," last revised July 23, 2014, revealed "Purpose Pocono Medical Center Emergency Department adopts the standards of care of the Emergency Nurses Association and outlines below aspects that are specific to the provision of emergency services in PMC [Pocono Medical Center] Emergency Department. Scope Emergency Department Registered Nurse ... Guidelines ... 4. Assessment of patients: a. Assessment can be divided into primary and secondary assessment. Assessments shall be initial and ongoing. ... 17. Reassessment of Patients: a. Patients that are in the treatment areas or triage area will be reassessed based on the patient level. .. e. A guideline for patients to be assessed and reassessed as follows: ... iii. Level 3 patients - reassessed every 2 hours or sooner if warranted by the patient's condition. VS [vital signs] every 2 hours or sooner if indicated."
Review of the American Heart Association document "Understanding Blood Pressure Readings," revealed the normal blood pressure category as systolic (upper number) less than 120, and diastolic (lower number) less than 80.
Review of MR1 revealed the patient presented to the Emergency Room on January 6, 2015, at 13:16 with the complaint of mid upper back pain. Triage was completed at 13:22. The patient's blood pressure was 173/96. Level 3 designation was assigned to MR1. The next documented blood pressure was 160/89 at 19:40. The patient's blood pressure on discharge at 22:30 was 178/96.
Interview with EMP1 on February 24, 2015, at approximately 11:00 confirmed the documentation of an elevated blood pressure at 13:22. EMP1 confirmed the next documented blood pressure was at 19:40 and was 160/89. EMP1 confirmed the facility policy for reassessment and vital signs was not followed.