HospitalInspections.org

Based on facility policy and procedure review, medical record review (MR), and staff interview (EMP), it was determined that the facility staff failed to take vital sign measurements according to the clinical practice guidelines and the physician order for 2 out of 8 patients (Patients #3 and #5) sampled that were treated in the emergency department (ED). Findings include:

Facility clinical practice guideline "Vital Sign Assessment-Emergency Department" effective January 9, 2013, and last reviewed October 19, 2023, revealed, "...Vital signs will be reassessed according to the patients Emergency Severity Index (ESI) level...ESI 2 and ESI 3: vital sign reassessment Q [every] 2 hours at minimum or until provider order..."

Facility policy "Standards of Care and Professional Nursing Practice" effective December 30, 1996, and last reviewed August 15, 2024, revealed, "...Vital signs, consisting of temperature, pulse, respirations, and blood pressure will be taken...ordered by the provider..."

Review of MR3 for ED visit dated 2/18/25 revealed:

- ED assessment completed on 2/18/25 at 8:16 AM revealed patient was given a tracking acuity (ESI) of 3.
- ED orders dated 2/18/25 at 8:06 AM stated "...vitals every 4 hours..."
- ED vital signs were completed on 2/18/25 at 8:08 AM and 2:43 PM, approximately 6.5 hours (1 set of vital signs not completed).

During an interview on 3/4/25 at 1:43 PM, EMP6 confirmed that Patient #3's vital signs were not completed according to the physician order.

Review of MR3 for ED visit dated 2/22/25 revealed:

- ED assessment completed on 2/22/25 at 11:27 PM revealed the patient was given a tracking acuity (ESI) of 2.
- ED vital signs were completed on 2/22/25 at 10:48 PM and 2/23/25 at 3:45 AM, approximately 5 hours (2 sets of vital signs not completed).

During an interview on 3/4/25 at 2:40 PM, EMP6 confirmed that Patient #3's vital signs were not completed according to the clinical practice guidelines.

Review of MR5 for ED visit dated 1/27/25 revealed:

-ED assessment completed on 1/27/2025 at 9:31 AM revealed patient was given a tracking acuity (ESI) of 3.
-ED orders dated 1/27/2025 at 1:08 PM stated, "...ED Protocol Order Discontinued...Order Vital Signs Every 4 Hours..."
-ED vital signs were completed on 1/27/25 at 9:23 AM and at 10:12 PM, approximately 12 hours and 49 minutes (3 sets of vital signs not completed).

During an interview on 3/5/25 at 11:07 AM, EMP4 and EMP6 confirmed that Patient #5's vital signs were not completed according to the clinical practice guidelines and the physician order.