HospitalInspections.org

Based on document review, medical record (MR) review and interview, emergency department (ED) staff did not ensure that emergency care was provided in accordance with generally accepted standards. Specifically, in 4 of 12 MRs reviewed, nursing staff did not obtain vital signs at frequencies required per ED policy and procedure (P&P). In 1 of 12 MRs reviewed, nursing staff did not document complete vital signs for a patient presenting with a mental health condition. This could cause staff to be unaware of a patient's declining condition.

Findings include:

-- Review of the facility P&P titled "Vital Signs," last reviewed 2/2017, indicated all patients should have a complete set of vital signs done and recorded that includes blood pressure (B/P), pulse (P), respirations (R) and pain level based on an assigned Emergency Severity Index (ESI) triage category. ESI levels include: #1- resuscitation, #2- emergent with abnormal vital signs, #3- urgent, #4- non-urgent and 5- referred. For example, an ESI of #2 with abnormal vital signs require staff to complete vitals signs every 30 minutes for one hour and then if stable, every 30 minutes for one hour, then every 1 hour x 2 followed by every 4 hours until an admission bed is available.

-- Review of Patient #1's MR revealed he presented to the ED via emergency medical services (EMS) from urgent care on 8/30/18 at 1:32 pm with chest pain and difficulty breathing. Staff triaged the patient at 1:49 pm and assigned an ESI level of #2. Patient #1's vital signs were abnormal: temperature (T)- 97.6 degrees Fahrenheit (F), P-91, B/P 117/84, R- 20 and 94% oxygen saturation on 4 liters of oxygen. Staff obtained vital signs again at 2:44 pm and B/P was 94/66 (abnormal). An additional set of vital signs were not obtained again until 4:10 pm (one hour and 25 minutes later). At that time B/P was 78/48 (abnormal). There was no documentation that vital signs were completed as required per P&P.

-- Review of Patient #2's MR revealed he presented to the ED via EMS on 4/30/18 at 2:52 pm with difficulty breathing. Staff triaged the patient at 3:46 pm and assigned an ESI level of #2. Vital signs were obtained and revealed a B/P of 143/88 (abnormal). Patient #2's vital signs were not obtained again until 6:37 pm (3 hours later). B/P at that time was 167/70. There was no documentation that vital signs were completed as required per P&P.

-- Review of Patient #3's MR revealed she presented to the ED on 7/7/18 at 9:01 pm with chest pain. Staff triaged the patient at 9:05 pm and assigned an ESI level of #2. Vital signs at that time were: B/P- 190/108 and P-134. Patient #3 remained in the ED and staff obtained vitals signs at 9:20 pm: BP-107/69 and P-109 and at 11:15 pm (approximately 2 hours later) BP-115/64 and P-90. There was no documentation that vitals were completed as required per policy.

-- Review of Patient #4's MR revealed she presented to the ED at 4:48 am, as a §9.41 Mental Health Law (MHL) emergency admission with local police. Staff triaged Patient #4 and assigned an ESI level #2. Staff obtained vital signs at 4:50 am, 5:12 am, 5:30 am, and 6:05 am. However, there was no documentation that staff obtained vital signs from 6:05 am until patient discharge from the ED at 1:30 pm (over 7 hours later). Additionally, vital signs obtained earlier were not complete, e.g., vital signs at 5:12 am did not include a temperature or respiration and vital signs at 6:05 am did not include a temperature and blood pressure. Each set of vital signs documented was not complete (i.e., T, P, R, B/P and oxygen saturation).

-- During interview of Staff A, Director of the ED on 10/16/18 at 12:30 pm, he/she indicated that a complete set of vital signs should include the temperature and oxygen saturation, however this is not included in their P&P. Staff A acknowledged the lack of acceptable frequency of vital signs in the MRs noted above and stated the vital sign P&P is due for revision.

Based on findings from document review and interview, 1 of 3 personnel files reviewed for nursing staff, Staff B, Registered Nurse (RN) lacked documentation of annual mandatory training (e.g., patient's rights, parents bill of rights, advance directives, infection control, fire safety).

Findings include:

-- Per review of personnel file for Staff B, employed since 7/2012, it lacked documentation of completion of the 2018 annual mandatory training.

-- During interview of Staff C, Director of Employee Relations on 10/17/18 at 2:30 pm, he/she stated that all staff are provided their annual mandatory education in May for completion.

-- During interview of Staff A, Director of Emergency Department on 10/16/18 at 2:30 pm, he/she stated that Staff B indicated the annual mandatory training was completed. However, there was no documentation of the completed training available to review.