HospitalInspections.org

Based on document review and interview it was determined that for 6 of 11 (Pt #1, 4, 5, 8, 9, 10) emergency department (ED) clinical records reviewed, the Hospital failed to ensure vital signs were reassessed as required per policy.

Findings include:

1. Policy entitled, "Assessments and Reassessment of Patients in ED" (Reviewed/Revised 3/2014) indicated, "Procedure: M. In addition, vital signs (blood pressure, pulse, respirations, and temperature) should be monitored as follows: 5. Vital signs should be taken at least every two (2) hours until discharged (excluding temperature unless indicated by condition). Vital signs will be taken on all patients upon discharge (with the exception of the fast tracks patients)."

2. The clinical record of Pt #1 was reviewed on 4/14/15. Pt #1 was a 57 year old male that presented to the Hospital's ED on 2/19/15 with complaints of abdominal pain. Pt #1 was triaged at 6:32 PM with vital signs documented as; temperature 98.9; pulse 92; respirations 19; blood pressure 100/57 and oxygenation 99%. Documentation included that Pt #1 was not reassessed until 10:00 PM (3 hours 30 minutes).

3. The clinical record for Pt #4 was reviewed on 4/15/15. Pt #4 was a 95 year old female that presented to the ED on 3/26/15 at 5:15 AM with a chief complaint of a fall and a subsequent diagnosis of a closed head injury without laceration. Pt #4 was triaged at 3/26/15 at 6:11 AM which included vital signs. The next reassessment of Pt #4's vital signs was on 3/26/15 at 6:57 AM. Pt #4's next vital sign reassessment was documented at 9:56 AM (3 hours 6 minutes).

4. The clinical record for Pt #5 was reviewed on 4/15/15. Pt #5 was a 64 year old male who presented to the ED on 3/27/15 at 4:02 PM by ambulance with a chief complaint of a right side crackles and shortness of breath (SOB) for three days. Pt #5 was triaged at 4:02 PM which included vital signs, with Pt #5's next documented vitals signs at 7:30 PM (3 hours 23 minutes). Pt #5's clinical record also lacked documentation of a reassessment of vital signs at the time of discharge, 11:09 PM.

5. The clinical record for Pt #8 was reviewed on 4/15/15. Pt #8 was a 75 year old male that presented to the ED on 3/29/15 at 1:04 PM via ambulance. Pt #8 presented with a chief compliant of an injury of the chest after a fall. Pt #8 was triaged at 1:04 AM which included vital signs. Pt#8 was discharged at 8:51 AM (8 hours 47 minutes), without documentation of vital sign reassessment.

6. The clinical record for Pt. #9 was reviewed on 4/14/15. Pt. #9 was a 30 year old female who presented in the ED on 4/14/15 at 3:04 AM with a chief complaint of abdominal pain and subsequent diagnosis of appendicitis. Pt. #9 was triaged on 4/14/15, with full vital signs taken at 3:04 AM however, vital signs were not reassessed again until 8:41 AM, an interval of 5 hours and 35 minutes.

7. The clinical record for Pt. #10 was reviewed on 4/14/15. Pt. #10 was a 58 year old female who presented in the ED on 2/19/15 at 8:40 AM with a chief complaint of leg pain status post fracture of the fibula on 2/1/15. Pt. #10 was triaged on 2/19/15 with full vital signs taken at 8:40 PM and repeated at 9:05 PM. However the vital signs were not reassessed again until 12:29 AM on 2/20/15, an interval of 3 hours and 24 minutes.

8. The ED Services Manager (E #1) stated during interviews on 4/14/15 at approximately 12:45 PM and on 4/15/15 at approximately 1:30 PM that the vital signs should have been reassessed every 2 hours.