HospitalInspections.org

a review of facility documents, medical records (MR) and staff interview (EMP). It was determined that the facility failed to reassess a patient's elevated blood pressure while in the Emergency Department for one of 10 medical records reviewed (MR2).

Findings include:

Review on October 5, 2016, of facility "Vital Sign Policy," last revised December 17, 2015, revealed "Policy: Vital signs (including temperature, pulse, respirations and blood pressure) are to be taken on all patients who present to the Emergency Department for treatment. All are to be documented in the patient's emergency room medical record. ... Patients who are in the emergency room longer than two hours and had abnormal vital signs (ie. Patients who present with an elevated temperature) upon presentation will have vital signs rechecked before discharge/disposition from the ER."

Review October 5, 2016, of MR2 revealed this patient presented to the facility's Emergency Department (ED) on August 7, 2016, at 21:05 PM by ambulance with a complaint of shortness of breath and an elevated blood pressure. Nursing documented this patient's blood pressure as 165 millimeters of mercury (mmHg) over 91 mmHg. Further review of MR2 revealed left the ED on August 8, 2016, at 00:56 AM. There was no documentation in MR2 indicating nursing re-checked this patient's blood pressure during MR2's stay in the ED.

Interview with EMP3 on October 5, 2016, at approximately 3:00 PM confirmed MR2 presented to the facility's Emergency Department (ED) on August 7, 2016, at 21:05 PM by ambulance with a complaint of shortness of breath and an elevated blood pressure; nursing documented this patient's blood pressure as 165 mmHg over 91 mmHg and that MR2 left the ED on August 8, 2016, at 00:56 AM. EMP3 confirmed there was no documentation in MR2 indicating nursing re-checked this patient's blood pressure during MR2's stay in the ED as per facility policy