HospitalInspections.org

Based on document review and staff interview, it was determined in 1 of 10 (Pt #1) medical record reviewed, the Hospital failed to ensure patients were being reassessed per Hospital policy, potentially affecting all patients receiving care at the Hospital.
Findings include:

1. On 11/23/15 at 11:00 AM, the medical record of Pt #1 was reviewed. Pt #1 was admitted to the Hospital on 9/1/15 due to a newly diagnosed malignancy. The patient was transferred to another Hospital on 9/5/15 at 5:59 PM. Documentation on the "Vital Signs" sheet indicated Pt #1 had a blood pressure recording of "92/50L" on 9/5/15 at 12:00 PM. There are no other recorded blood pressure readings, after 12:00 PM.

2. On 11/24/15 at 1:00 PM, the Hospital policy "General Assessment, Monitoring & Physical Care" effective 12/2014, was reviewed. Under "II. Policy: if blood pressure is abnormally high or low, it should be repeated in the opposite arm (in the absence of a contraindication) and compared to the initial reading."

3. On 11/24/15 at 10:40 AM, an interview with the telemetry nurse (E #9) was conducted. E #9 agreed that the vital sign sheet for Pt #1 did contain a reading of 92/50L and verbalized the "L" next to the blood pressure reading indicated the blood pressure reading was abnormally low. E #9 also verbalized that she was aware of the abnormal reading and the nursing technician, responsible for retaking the blood pressure, took another set of vitals on Pt #1, and it was within normal limits "The nursing technician failed to update the electronic medical record to reflect the repeated, blood pressure reading."