HospitalInspections.org

Based on medical record review, document review and interviews, the facility staff failed to monitor vital signs in accordance with their policy and procedure for six (6) out of twenty (20) patients included in the survey sample.

The findings included:

Twenty (20) medical records were reviewed during an EMTALA investigation. Six (6) of the twenty medical records failed to evidence vital sign monitoring every two hours and six of twenty medical records failed to evidence vital signs taken at discharge.

The six incomplete emergency department (ED) medical records evidenced the following:
Patient 1- arrived at 9:44 a.m., vital signs were obtained only at 10:01 a.m. and patient was discharged at 2:59 p.m. (total ED time 2 hours and 15 minutes)
Patient 2- arrived at 8:02 a.m., vital signs were obtained only at 8:27 a.m. and patient was discharged at 10:08 p.m. (total ED time 14 hours and 6 minutes)
Patient 3- arrived at 11:54 a.m., vital signs were obtained only at 12:06 p.m. and patient was discharged at 8:11 p.m. (total ED time 8 hours and 17 minutes)
Patient 6- arrived at 11:57 a.m., vital signs were obtained only at 12:04 p.m. and patient was discharged at 4:26 p.m. (total ED time 4 hours and 29 minutes)
Patient 14- arrived at 11:01 p.m., vital signs were obtained only at 11:15 p.m. and patient was discharged at 3:16 a.m. (total ED time 3 hours and 17 minutes)
Patient 16- arrived at 3:19 p.m., vital signs were obtained only at 3:21 p.m. and patient was discharged at 8:13 p.m. (total ED time 4 hours and 54 minutes)

A facility policy, titled "Emergency Services: Clinical Staff, Expectations and Performance", last effective date 08/2022, was reviewed and evidenced, in part, "IV. Procedure:...B. Accountability:...2. Vital Signs and Assessment: b...Obtain a complete set of vital signs and document findings in the patient's record: i....A minimum of every two (2) hours and more frequently as patient condition dictates...iii. At discharge from the Emergency Department."

In an interview with Staff Member 12 (SM12- ED Director) on 2/22/23 at 11:10 a.m., when asked about vital sign monitoring in the ED, they stated, in part, "It is every two hours per our policy, sheer volume in the ED makes this impossible at times, I'm just being transparent."

The surveyor discussed the concerns with staff during the exit conference on 2/22/23 at approximately 2:15 p.m.