HospitalInspections.org

Based on review of hospital policies and procedures, Patient #1's medical record, and staff interviews, it was determined the nurse executive failed to require nursing staff monitor and document patient #1's vital signs as required by the Physician's order. This deficient practice poses the potential risk to patient health and safety when the physician does not have pertinent information to treat the patient.

Findings Include:

The "Vital Signs" policy, revised 03/2019, requires the following: "...Vital signs will be taken at the time of admission, as ordered by the practitioner and no less frequently than once a day...The staff member who takes the vital signs will alert the Registered Nurse immediately if they are out of range, based on history or normal ranges...Vital signs will be repeated at a frequency determined by the Registered Nurse if they are abnormal...The Registered Nurse will contact the practitioner if the vital signs continue to be abnormal ...."

The "Vital Signs" policy did not contain parameters for normal or out of range vital signs.

The medical record contained an order to monitor the patient's vital signs daily.

The medical record contained the following vital signs:

11/28/2019 at 4:55 pm: The patient refused to have vital signs checked.
11/28/2019 at 17:00: Temp 98.5, pulse 106, BP 113/79, Resp 17, O2 Sats 87%
11/30/2019 at 5:31: Blood Pressure 120/83, Pulse 99, Resp 20, O2 Sats 92%, Temp 97.7
12/2/2019 at 5:13: Blood Pressure 129/75, Pulse 90, Resp 16, O2 Sats 91%, Temp: Not documented
12/3/2019 at 5:08: Blood Pressure 129/79, Pulse: NOT DOCUMENTED, Resp: Not documented, Temp: Not documented
12/5/2019 at 5:26: Blood Pressure: 136/79, Pulse 107, Resp: 19, Temp: 97.4
12/6/2019 at 5:41: Blood Pressure 111/65, Pulse 112, Resp: 18, Temp: 97.2
12/08/2019 at 5:37: Blood Pressure 124/57, Pulse 120, Resp: 20, Temp: 98.4

Vital signs were not documented on 11/29/2019, 12/1/2019, 12/4/2019, or 12/7/2019. The oxygen level was not documented on 12/03/2019, 12/5/2019, 12/6/2019, or 12/08/2019.

The medical record did not contain documentation the nurse notified the physician regarding the oxygen saturation of 87% on 11/28/2019, 92% on 11/30/2019, 91% on 12/02/2019, or the pulse of 120 on 12/08/2019.

Employee #1 confirmed in an interview conducted on 12/12/2019, the patient's vital signs were not documented as required by hospital policy and provided the following information related to vital sign parameters: "...Parameters for BP, Pulse, Resp, Temp, O2 Sat & Intake are in italics. If ranges are above/below the parameters, you must notify the RN immediately...BP <90/60 mmHg or >160/100...Pulse <50 bmp or >100 bmp...Respiration <12/min or >20/min...Temp <96.0 F or >100.0 F...O2 Sat <93%...."