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Based on medical record review and document review, the medical staff was not accountable for the quality of the medical care provided to Patient #1 relative to lack of assessment after provider notification of sepsis alert. This has the potential to affect patient outcome and care provided.

Findings include:

Review of facility Policy and Procedure entitled "Adult Sepsis Protocol" issued 7/5/16 revealed the following:
- (A) SIRS (systemic inflammatory response syndrome): the body's response to an infection or noninfectious insult:
Hyperthermia greater than 38.3C
Tachycardia greater than 90 beats per minute
Leukocytosis (greater than 12,000)
- Sepsis Progress Note:
Used to assist providers in documenting their assessment of a septic patient.
Used to assist providers in documenting their rationale for not completing the 3 and 6 hour bundle requirements due to either an approved exclusion criteria, or clinical scenario a provider feels would make it unsafe or unwarranted.
- Expected course of action to be completed within three hours if recognition of sepsis: Measure lactate level, obtain blood culture prior to antibiotic administration, administer broad spectrum antibiotics, administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L.

Review of Provider Notification Documentation in medical record on 2/25/17 revealed the following:
- Time Provider Notified: 5:27 AM
- Time Provider Responded: 5:31 AM
- Reason for Provider Notification: SIRS (systemic inflammatory response syndrome) Alert
- SIRS Criteria: 2/24/17 8:40 PM: WBC (white blood cell count) 14.4 (criteria: greater than or equal to 12.1). 2/25/17 5:19 AM: Heart Rate 111 (criteria: greater than or equal to 96). 2/25/17 5:19 AM: Temperature=38.8 (criteria: greater than or equal to 38.4).

No documentation of medical provider assessment found in medical record until 4:44 PM on 2/25/27

Based on medical record review, document review and interview, nursing staff did not monitor vital signs on Patient #1 while in the Emergency Department in accordance with facility protocol. This has the potential to result in delay in treatment.

Findings include:

Review of facility Policy and Procedure entitled "Measurement of Vital Signs in the Emergency Department" revised 6/14 revealed that vital signs will be measured and recorded every four (4) hours, or more frequently as clinically indicated. Patients who are being transported out of the department for any reason (i.e. testing or admission) will have vital signs measured and recorded within 30 minutes prior to their departure from the ED.

Review of Vital Signs in ED revealed the last recorded vital signs in the ED were dated 2/25/18 at 3:00 AM. Heart Rate EKG 104, B/P 92/66, Respiratory Rate 25, SpO2 97%.

Review of the Intrahospital Transfer Form for ED transfer to medical floor dated 2/25/17 at 5:25 AM revealed patient's transfer condition: stable. Vital Signs (page 2) of Intrahospital Transfer Form not completed before transfer from ED to medical floor.

Review of ED nursing documentation dated 2/25/17 revealed the patient was transferred to the medical floor at 5:15 AM on 2/25/17.

Review of vital signs upon admission to medical floor dated 2/25/18 at 5:19 AM revealed Temp. 38.8 C (101.8F), Pulse Rate 111, B/P 134/61, Respiratory Rate 18, SpO2 98%. Due to elevated temperature, heart rate and white blood cell count, SIRS (systemic inflammatory response syndrome) alert was activated.

Interview with Staff C (Quality Officer) on 5/8/18 at 3:30 PM verified the above findings.