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Based on review of records and interview, nursing staff failed to keep the nursing plan of care current in 1 (Patient #14) of 18 charts reviewed by failing to update vital signs for reassessment at specified frequency.

Review of Patient #14's record showed that she was an 83 year old female who presented to the Emergency Department (ED) by private automobile using a wheelchair. She reported she had been having shortness of breath since the previous night. At 16:08 the medical record showed she had been triaged for acuity with an Emergency Severity Index rating of 3 (ESI 3), Urgent.

Review of the policy titled Standards of Practice or Care, Policy Number: ED10 revealed the following:

"Standard I. B. 3. 3. ESI 3; Urgent- Condition that have potential to progress to serious problems requiring emergency intervention. Need frequent reassessment."

"Standard III. N. Fundamental Emergency Department nursing interventions include, but are not limited to the following.
2. Vital signs every two (2) hours on ESI 3 patients, unless ordered more frequently.
4. Vital signs will be repeated if not within normal limits, as follows:
a. Adult ranges:
(1) Temp: 96-101 degrees F;
(2) BP: 100/60 - 140/90 mm/Hg;
(3) Pulse: 60-100 bpm;
(4) RR: 12-24 / min."

Further review of patient record showed the following documented vital signs:

16:05 Blood Pressure 151/79; Pulse 71; Respirations 20; Temperature 97.9; Pulse Oxygen Level 90% on room air.

16:05 Pulse Oxygen Level 95% on oxygen flowing at 2 liters per minute through a nasal cannula (tubing connected to oxygen with two small prongs that fit into the nostrils to deliver oxygen to the patient).

17:40 Pulse Oxygen Level 90% on room air.

21:58 Blood Pressure 172/84; Pulse 74; Respirations 20; Temperature 97.6; Pulse Oxygen Level 95% on oxygen flowing at 3 liters per minute through a nasal cannula .

Per the policy, vital signs should have been documented at 18:05 and 20:05 but were not. The systolic blood pressure (first number listed) was outside of range in both instances without documentation that the blood pressure was rechecked.

Interview was conducted with Staff #6. Staff #6 stated that ED nurses are educated on the policy for Standard of Care. Staff #6 confirmed that the vital signs had not been updated.