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Based on the review of hospital policies and procedures, medical record reviews and staff interviews, the hospital staff failed to assess vital signs per physician's order for 2 of 2 sampled patients with sepsis diagnosis. (Patient #5 and #9)

Findings included:

Review on 07/24/2018 of the hospital policy and procedure titled "Assessments/Reassessments (...Adult Inpatient)" updated 05/2017 revealed "Reassessment A. Reassessments will occur based on patient condition and unit location. ...c. Critical Care: every 4 hours and as needed."

1. Review on 07/24/2018 of the medical record for Patient #5 revealed an 87 year-old male presented to the Emergency Department via ambulance on 07/10/2018 at 0212 with a chief complaint of left flank pain and generalized weakness. Review of the Triage Nursing report dated 07/10/2018 at 0215 revealed vital signs blood pressure 79/41, heart rate 98, respiratory rate 20, temperature 97.6 orally and oxygen saturation 95% on room air. Further review revealed documented weight 70.1 kilograms, height 64 inches and pain score 8/10 with pain in left flank described as aching. Review of the medical record revealed Sepsis (potentially life-threatening complication of an infection) physician order set and protocol were initiated in the Emergency Department. Review of the medical record revealed Patient #5 was admitted on 07/10/2018 at 0411 with diagnoses of severe neutropenia (abnormally low level of neutrophils a common type of white blood cell important to fighting off infections) and hypotension (low blood pressure). Review of the physician orders revealed an order for "Full Code" (use of all means of resuscitation) and documentation of Patient #5's condition as "Critical". Further review of the physician orders revealed orders dated 07/10/2018 at 0420 for vital signs every two (2) hours, cardiac monitor, continuous pulse oximetry (means to measure oxygen levels in the blood), oxygen 2 liter per minute via nasal cannula and to titrate oxygen to keep oxygen saturations greater than 90 percent.

Review of the admission nursing assessment revealed Patient #5 arrived in the Critical Care unit on 07/10/2018 at 0444 and the admission assessment was completed. Admission assessment revealed documentation that the cardiac monitor was placed on the patient and the monitor alarm parameters were set. Review of the vital signs report dated 07/10/2018 revealed vital signs (blood pressure, heart rate, respiratory rate, temperature and oxygen saturation) were documented at 0500, 0700 and 2017. Review of the vital signs documented at 2017 revealed an oral temperature of 94.6 (2 degrees below sepsis order parameter [96.8] and 4 degrees below normal [98.6]) and notification to the provider that the bair hugger (warming blanket) was being used on another patient and the nurse had placed additional blankets on the patient. Review of the medical record revealed no additional physician orders received. Further review of the medical record revealed no available documentation of a temperature recheck prior to Patient #5's death at 2333. Review of the vital signs report dated 07/10/2018 revealed vital signs (blood pressure, heart rate, respiratory rate and oxygen saturation) documented at 0900, 1100, 1300, 1500, 1700, 1900 and 2200. Review of the medical record revealed no available documentation of a temperature at 0900, 1100, 1300, 1500, 1700, 1900 and 2200. Record review revealed a documented temperature of 97.5 on 07/10/2018 at 0700 and the next available temperature of 94.6 was documented at 2017 (13 hours and 7 minutes later). Review of the vital signs report for 07/10/2018 at 2148 revealed Patient #5's oxygen saturation was documented at 93% and the nurse placed on oxygen (one) 1 liter via nasal cannula at 2148. Review of the vital signs report dated 07/10/2018 revealed vital signs (blood pressure, heart rate and respiratory rate) documented at 2300. Review of medical record revealed no available documentation of a temperature and oxygen saturation on 07/10/2018 at 2300. Review of the cardiac monitoring rhythm strips revealed documentation of Sinus Rhythm (normal heart rhythm) on 07/10/2018 at 0529, 0700, 1100, 1500 and 1900. Further review revealed no available documentation of a rhythm strip documented at 2300 and no documentation of the rhythm strips obtained during the resuscitation from 2311 to 2333. Record review revealed the hospital staff failed to obtain vital signs, to include a temperature, every two (2) hours as ordered by the physician.

Interview on 07/25/2018 at 1620 with the unit nursing manager revealed the staff were expected to reassess vital signs per physician orders. Interview revealed a set of vital signs included temperature, heart rate, respiratory rate, blood pressure and oxygen saturation. Interview revealed the staff failed to follow the physician order to check vital signs every 2 hours. Interview revealed she would expect the staff to recheck an abnormally low oral temperature rectally for verification of accuracy.

Interview on 07/25/2018 at 1055 with the primary care registered nurse that was assigned to Patient #5 on 07/10/2018 revealed she had worked at the hospital for 10 years and had worked in the critical care unit for 5 years. Interview revealed she placed the patient on the cardiac monitor and obtained manual temperatures every four (4) hours. Interview revealed if the physician ordered vital signs every two (2) hours, she should have obtained a temperature every two (2) hours along with the blood pressure, heart rate, respiratory rate and oxygen saturation. Interview revealed she obtained the oral temperature of 94.6 on 07/10/2018 at 2017 and did not recheck a rectal temperature. Interview revealed she should have rechecked the temperature rectally and she normally did recheck. Interview revealed she should have rechecked the temperature within a couple of hours after the blanket intervention. She stated she contacted the physician about the temperature and placed blankets on the patient as the bair hugger was being used on another patient.

2. Review on 07/25/2018 of the medical record for Patient #9 revealed a 65 year-old female presented to the Emergency Department via ambulance on 07/24/2018 at 0229 with chief complaint of fever and abdominal incision drainage. Review of the Triage Nursing report dated 07/24/2018 at 0233 revealed vital signs blood pressure 97/45, heart rate 109, respiratory rate 23, temperature 101.3 orally and oxygen saturation 97% on 2 liters of oxygen. Further review revealed documented weight 83.2 kilograms, height 72 inches and pain score 8/10 with pain in abdomen. Review of the medical record revealed Sepsis physician order set and protocol were initiated in the Emergency Department. Review of the medical record revealed Patient #9 was admitted on 07/24/2018 at 0513 with diagnoses of sepsis, infected wound from previous surgery and right leg cellulitis. Further review of the physician orders revealed orders dated 07/24/2018 at 0509 for vital signs every hour times six (6) then every 4 hours. Review of the vital signs report dated 07/24/2018 revealed vital signs (blood pressure, heart rate, respiratory rate, temperature and oxygen saturation) were documented at 0500, 0600 and 1000. Review of the vital signs report dated 07/24/2018 revealed vital signs (blood pressure, heart rate, respiratory rate and oxygen saturation) documented at 0700, 0800 and 0900. Review of the medical record revealed no available documentation of a temperature at 0700, 0800 and 0900. Record review revealed the hospital staff failed to obtain vital signs, to include a temperature, every hour times six (6) as ordered by the physician.

Interview on 07/25/2018 at 1620 with the unit nursing manager revealed the staff were expected to reassess vital signs per physician orders. Interview revealed a set of vital signs included temperature, heart rate, respiratory rate, blood pressure and oxygen saturation. Interview revealed the staff failed to follow the physician order to check vital signs every hour times six (6).

NC00140922
NC00139703