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HUNTINGTON HOSPITAL
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
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Based on Medical Record review, document review and interview, the facility did not ensure vital signs were recorded as per prescriber order.
Findings:
Review of Patient #2's Medical Record identified that vital signs ordered and taken every hour on 03/28/18 from 10:00AM to 3:00PM, were not recorded in the Medical Record until 7:00PM.
The same lack of timely vital sign documentation was identified in the Medical Records of Patients #15 and #16.
Per interview with Staff K (Registered Nurse) on 11/16/18 at 11:30AM and Staff L (Registered Nurse) at 12:30PM, both stated it was common practice to chart at the end of the shift.
Per interview with Staff A (Vice President of Quality) on 11/16/18 at 11:00AM, documenting at the end of the shift was not the best practice.
The facility Policy and Procedure titled "Vital Signs for Adult and Pediatric Patients" last revised 06/21/18, stated that "vital signs will be taken and recorded as warranted by...prescriber order..."