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Based on clinical record review, staff interview and policy review it was determined the facility failed to reassess and complete vital signs for 2 (#1, #2) of 4 sampled patients according to policy in the Emergency Department. The practice may result in a delay of patient treatment.

Findings include:

1. Patient #1 presented to the Emergency Department (ED) on 10/10/11 at 1:43 a.m. with complaints of chest pain and high blood sugar. The patient was triaged as a level 3 acuity. The vital signs were obtained at 1:50 a.m. The blood pressure was 162/104. A second set of vital signs and assessment were obtained at 7:48 a.m., approximately 6 hours after the patient arrived.

A review of the facility's policy, "Plan of Care for Emergency Department", policy #ET-4, revised 10/05, section I., Assessment, paragraph (7) revealed: Triage category is assigned, utilizing subjective and objective data gathered. "Level 3-Urgent, requires reassessment every 2-3 hours until stabilized". A review of page 4 of 4, section IV. evaluation, paragraph A. revealed "reassessments are performed and documented, in accordance to the time frame, as determined by their assigned triage category.

An interview with the ED manager conducted on 10/25/11 after review of the clinical record on paper format and computer access confirmed the patient had not been reassessed and vital signs had not been obtained according to the triage acuity level assigned to the patient.

2. Patient #2 presented to the ED on 10/10/11 at 7:58 p.m. with complaints of a history of diabetes and nausea, vomiting and diarrhea. A finger stick blood sugar was obtained at 8:41 p.m. that showed greater than 500 (70-110). The blood pressure was 110/62. The patient was triaged at 8:50 p.m. as a level 2 acuity. At 9:30 p.m. the patient complained of chest pain. A focused assessment was completed but no vital signs were obtained. The next set of vital signs were completed at 11:11 p.m. The blood pressure was 91/47, approximately 2.5 hours later. The patient was admitted to the Intensive Care Unit with the diagnosis of Diabetic Ketoacidosis and dehydration.

A review of the facility's policy, "Plan of Care for Emergency Department", policy #ET-4, revised 10/05, section I., Assessment, paragraph (7) revealed: Triage category is assigned , utilizing subjective and objective data gathered. "Level 2-Emergent requires reassessment and vital signs every 15-30 minutes until stabilized. A review of page 4 of 4, section IV. evaluation, paragraph A. revealed "reassessments are performed and documented, in accordance to the time frame, as determined by their assigned triage category.

An interview with the ED manager conducted on 10/25/11 after review of the clinical record on paper format and computer access confirmed the patient had not been reassessed and vital signs had not been obtained according to the triage acuity level assigned to the patient.