HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to:
- Monitor post-operative vital signs for five (#4, #1, #36, #37 and #38) of seven patients' records reviewed for post-operative vital signs. Failure to closely monitor post-operative patients could potentially lead to undetected changes in the patient.
- Remove hazardous items from the possession of one (#26) of one suicidal patient's record reviewed. Failure to remove hazardous items from a suicidal patient potentially leads to the patient harming self or others.
The facility census was 444.

Findings included:

1. Record review of the facility's policy titled, "Postoperative Management", dated 10/15/09 showed the following direction:
- Assess: Blood pressure, respiratory rate, pulse (vital signs).
- Frequency: Upon arrival and every 15 minutes for one hour, then vital signs per standard.

2. Review of Patient #4's medical record showed the patient had surgery on 08/24/11 and arrived on 8 East, surgical floor, at 1:40 PM. The nursing staff failed to take post-operative vital signs at 2:10 PM, 2:25 PM and 2:40 PM and the next vital signs were taken at 2:46 PM (48 minute gap instead of every 15 minutes per policy). The nursing staff failed to take post-operative vital signs at 3:10 PM and the next vital signs were taken at 3:26 PM (40 minute gap instead of 30 minutes per their stated routine). The nursing staff failed to take post-operative vital signs at 3:40 PM and the next vital signs were taken at 4:12 PM (46 minute gap instead of 30 minutes per their stated routine). The vital signs taken at 4:12 PM were blood pressure of 202/93 (high), heart rate of 115 (high) and no respiratory rate documented. The patient was resuscitated from approximately 4:00 PM to 4:35 PM at which time the patient returned to surgery.

During an interview on 09/07/11 at approximately 1:40 PM, Staff JJ, Registered Nurse (RN), Director of Nursing, stated that Patient #4's vital signs were not monitored per policy.

3. Review of Patient #1's medical record showed the patient had surgery on 08/29/11 and arrived on 8 West, surgical floor, at 4:10 PM. The nursing staff failed to take post-operative vital signs at 4:25 PM and the next vital signs were taken at 4:40 PM (30 minute gap instead of 15 minutes per policy). The nursing staff failed to take vital signs at 5:10 PM and the next vital signs were taken at 5:25 PM (30 minute gap instead of 15 minutes per policy).

During an interview on 09/01/11 at 2:00 PM, Staff E, RN, Charge Nurse, stated that post-operative vital signs were to be taken every 15 minutes for one hour then every 30 minutes for two hours.

4. Review of Patient #36's medical record showed the patient had surgery on 09/07/11 and arrived on 8 West, surgical floor, at 5:30 PM. The nursing staff failed to take post-operative vital signs at 6:30 PM and the next vital signs were taken at 6:45 PM (28 minute gap instead of 15 minutes per policy).

5. Review of Patient #37's medical record showed the patient had surgery on 09/06/11 and arrived on 8 West, surgical floor, at 3:40 PM. The nursing staff failed to take post-operative vital signs at 4:25 PM and the next vital signs were taken at 4:45 PM (30 minute gap instead of 15 minutes per policy). The nursing staff failed to take post-operative vital signs at 5:40 PM and the next vital signs were taken at 7:55 PM (two hour and 25 minute gap instead of 30 minutes per their stated routine).

6. Review of Patient #38's medical record showed the patient had surgery on 09/07/11 and arrived on 8 East, surgical floor, at 1:00 PM. The nursing staff failed to take post-operative vital signs at 1:30 PM and the next vital signs were taken at 1:41 PM (26 minute gap instead of 15 minutes per policy). The nursing staff failed to take post-operative vital signs at 2:00 PM and the next vital signs were taken at 2:16 PM (35 minute gap instead of 15 minutes per policy).

During an interview on 09/08/11 at 10:45 AM Staff RR, Quality Compliance Coordinator, stated that staff failed to obtain post operative vital signs every fifteen minutes as per policy.

7. During an interview on 09/08/11 at 9:48 AM, Staff D, RN, Vice President of Nursing Services, stated that he/she would expect post-operative vital signs to be taken per policy.

8. Record review of the facility's policy titled, "Suicidal/Homicidal Patient in an Acute, Non-Psychiatric Setting", dated 02/11/11, showed the following direction:
- Have patient remove all clothing and belongings.
- Search the newly hospitalized patient and their belongings.

9. Review of current Patient #26's medical record showed he/she was admitted on 08/24/11 for Diabetic Ketoacidosis (dangerously high blood sugar level) and Pancreatitis (inflammation of the Pancreas). During the admission interview on 08/24/11 at 10:41 AM, he/she was assessed as having anxiety, depression, panic attacks, superficial cuts to both wrists and suicide issues. On 08/24/11, the physician ordered Patient #26 to be placed on suicide precautions. On 08/26/11 at 7:15 AM, staff found Patient #26 in the bathroom with the drawstring from his/her gym shorts tied around his/her neck and the shower curtain rod. The nursing staff cut the drawstring and released Patient #26 without injury.

Review of the facility's investigation of this incident showed Patient #26 was transferred from 3 East to 4 West. The patient was wearing personal shorts with a drawstring upon arrival to 4 West. The receiving unit was told that the patient was wearing gown and underwear. Staff did not inspect the patient ' s shorts during the physical assessment.

During an interview on 09/02/11 at 11:37 AM, Staff I, RN, Patient Safety Officer, stated that Patient #26 was wearing a hospital gown and gym shorts with a drawstring tie. The patient had gotten up to the bathroom, pulled the curtain to allow privacy and then was found by the sitter hanging from the shower curtain rod and his/her gym short's drawstring. Staff I stated that the policy was to search and remove items of potential harm (including gym shorts with drawstring) and that was not done with Patient #26.


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