HospitalInspections.org

Based on policy review, medical record review, and interview the hospital failed to ensure physician's orders for vital signs assessments were followed for 1 of 7 (Patient #5) sampled patients.

The findings included:

1. Review of the hospital policy titled, "Nursing Documentation of the Patient Medical Record" revealed, "...Re-assessment is completed based on patient acuity with specific guidelines established by each department...As ordered by the Provider...Nursing documentation...Assessments..."

2. Medical record review for Patient #5 revealed a 28 year old male hospitalized 10/9/2023 through 10/10/2023 for a scheduled partial nephrectomy (kidney removal) to remove a mass from his left kidney.

Review of the Operative Report dated 10/9/2023 revealed, "...Indication for Surgery [Named Patient #5] is a 28 y/o [year old] M [male] with an incidentally found large left renal [kidney] mass with invasion in to the collecting system who presents today for Robot-assisted laparoscopic left partial vs radical nephrectomy [total kidney removal]...Preoperative Diagnosis Left renal mass...Findings 1. Left partially exophytic renal mass [mass growing from the outer surface of the kidney] with invasion in to collecting system and major branches of renal artery 2. Conversion to radical nephrectomy...The patient tolerated the procedure well, without any complications..."

Review of a Physician's Order dated 10/9/2023 at 11:33 AM revealed, "...Vital Signs...q [every] 4h [hours]..."

Review of the nursing Flowsheet, "Vital Signs" section revealed Patient #5's vital signs were assessed at 8:45 PM on 10/9/2023. There was no documentation the patient's vital signs were re-assessed until 4:00 AM on 10/10/23, a total of 6 hours and 15 minutes later.

Further review of the nursing Flowsheet, "Vital Signs" section revealed Patient #5's vital signs were assessed at 7:49 AM on 10/10/2023. There was no documentation the patient's vital signs were re-assessed until 3:55 PM, a total of 8 hours and 6 minutes later.

In an interview on 3/4/2024 at 3:25 PM, the Director of Quality verified nursing staff failed to assess Patient #5's vital signs every 4 hours as ordered by the physician.

In an interview on 3/5/2024 at 11:18 AM, Registered Nurse (RN) #1 verified Patient #5's vital signs were not assessed every 4 hours as ordered by the physician.

In a telephone interview in the presence of the Director of Quality on 3/5/2024 at 11:40 AM, RN #2 verified vital signs should be assessed as ordered by the physician. RN #2 was asked who was responsible for assessing patient's vital signs. The RN stated, "I am."