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Based on record reviews and interviews, the facility failed to ensure nursing staff completed vital sign assessments according to established guidelines and facility policy in five of twenty three medical records reviewed. (Patients #5, 11, 12, 19, and 21)

Findings include:

Facility policy:

According to the policy Assessment, Reassessment, Vital Signs, and Documentation of Patient Care, initial and ongoing vital sign assessments should be performed according to the patient's Emergency Severity Index (ESI, a five level triage algorithm that provides clinically relevant stratification of patients into five groups from one (most urgent) to 5 (least urgent) on the basis of acuity and resource needs) triage level.

An Emergency Department (ED) patient with a triage level ESI-2 (emergent) must have a vital sign assessment upon arrival. Then at a minimum of every hour for four hours. Then every two hours if clinically stable and one hour prior to transfer or discharge from the unit.

An ED patient with a triage level ESI-3 (urgent) must have a vital sign assessment upon arrival. Then patients with normal vital signs at a minimum of every four hours. Patients with abnormal vital signs, must have vital signs reassessed at a minimum of every two hours for four times. Then every four hours if clinically stable and one hour prior to transfer or discharge from the unit.

An ED patient with a triage level ESI-4 or ESI-5 (non-urgent and referrals) must have a vital sign assessment upon arrival. Then at a minimum of every four hours and PRN (as needed) based on patient condition and one hour prior to transfer or discharge from the unit.

Reference:

According to the American Nurses Association (ANA) Standards of Care: The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making.

Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation.

1. The facility failed to ensure vital signs were monitored per facility policy.

A. Medical record reviews revealed nursing staff did not document vital signs in accordance with facility policy for vital sign assessment and reassessment in the ED

i. A review of Patient #21's medical record revealed the patient arrived at the ED on 4/3/23 at 7:52 p.m. with a chief complaint of alcohol intoxication. The patient was triaged at a level ESI-3 (urgent). The patient was examined, treated, and discharged at on 4/4/23 at 5:03 a.m. The last set of vital signs prior to discharge were taken on 4/3/23 10:00 p.m., which was seven hours prior to the patient's discharge.

This was in contrast with the Assessment, Reassessment, Vital Signs and Documentation of Patient Care policy which instructed that a patient with a triage level ESI-3 should have received vital signs assessments initially upon arrival, a minimum of every four hours for patients with normal vital signs, a minimum of every two hours times four for patient with abnormal vital signs, and one hour prior to discharge or transfer from the unit.

ii. A review of patient #5's medical record revealed the patient arrived at the ED on 3/9/23 at 8:37 p.m. by ambulance. The patient was brought to the ED for a psychiatric evaluation. Vital signs were taken upon arrival at 8:44 p.m. The patient was triaged at a level ESI-2 (emergent). Vital signs were taken again at 9:22 p.m. The next vital signs were recorded on 3/10/23 at 8:07 a.m., which was approximately 11 hours later. The next set of vital signs were recorded more than five hours after that at 1:30 p.m. The patient was medicated with Haldol (antipsychotic medication) and Ativan (medication used to treat anxiety) at 5:20 p.m. No further vital signs were taken and the patient was transferred out of the unit at 8:50 p.m., which was three and a half hours after being medicated and over seven hours since the last set of vital signs.

This was in contrast with the Assessment, Reassessment, Vital Signs and Documentation of Patient Care policy which revealed a patient with a triage level ESI-2 should have received vital signs initially upon arrival, a minimum of every hour for four hours, then every two hours if clinically stable, and one hour prior to discharge or transfer from the unit.

iii. A review of patient #12's medical record revealed the patient presented at the ED on 2/13/23 at 8:50 p.m. with a complaint of side and chest pain after a fall at home. Triage vital signs were recorded at 9:06 p.m. The patient was triaged at a level ESI-4 (non-urgent). The patient's vital signs were recorded again at 10:00 p.m. The patient was examined, received x-rays and pain medications. The patient was then discharged to home at 11:18 p.m., over an hour since the last set of vital signs were taken.

This was in contrast with the Assessment, Reassessment, Vital Signs and Documentation of Patient Care policy which revealed a patient with a triage level ESI-4 should have received vital signs initially upon arrival, a minimum of every four hours, and one hour prior to transfer or discharge from the unit.

iv. A review of patient #11's medical record revealed that the patient presented at the ED on 3/7/23 at 11:04 a.m. with a complaint of rib pain. Triage vital signs were recorded at 11:11 a.m. The patient was triaged at a level ESI-4. The patient was examined, received x-rays, and discharged to home at 1:04 p.m. The patient was discharged with instructions and a prescription for pain medicines, however vital signs had not been taken for over two hours prior to discharge.

This was in contrast with the Assessment, Reassessment, Vital Signs and Documentation of Patient Care policy which revealed that a patient with a triage level ESI-4 should have received vital signs initially upon arrival, a minimum of every four hours, and one hour prior transfer or discharge from the unit.

v. A review of patient #19's medical record revealed that the patient presented to the ED on 10/13/22 at 7:49 p.m. with chief complaint of chest pain. The patient was triaged at a level ESI-2 with vital signs taken at 7:53 p.m., 9:00 p.m., 10:00 p.m., 11:00 p.m., 10/14 /22 12:00 a.m., and 1:00 a.m. The patient was treated and stabilized then transferred to a higher level of care at 2:15 a.m. The patient did not receive an additional set of vital signs within an hour prior to transfer.

This was in contrast with the Vital Signs and Documentation of Patient Care policy which revealed a patient with a triage level ESI-2 should have received vital signs initially upon arrival, a minimum of every hour for four hours, then every two hours if clinically stable, and one hour prior to discharge or transfer from the unit.

B. Interviews revealed while caring for patients #5, 11, 12, 19 and 21, nursing staff did not document vital signs in accordance with facility policy for vital sign assessment and reassessment in the ED.

i. In an interview with registered nurse (RN) #1 on 4/18/23 at 2:20 p.m., RN #1 stated for a patient triaged as an ESI-4, vital signs would be assessed at a minimum at triage. RN #1 stated if the patient was not discharged for a couple hours then the expectation would be that vital signs be assessed again. For a patient with an ESI-2, RN #1 explained that vital signs would be taken upon arrival and then every 15-30 minutes, after interventions, and at discharge. RN #1 said that if vital signs were not reassessed there was a risk that nursing staff could miss a deterioration in the patient's condition.

ii. In an interview with RN #2 on 4/18/23 at 12:33 p.m., RN #2 stated that vital signs should be taken at triage and any time after an intervention such as the administration of pain medication. Further, RN #2 stated that there was a risk of patients deteriorating if vital signs were not assessed regularly.

iii. In an interview with ED Director #3 on 4/19/23 at 11:00 a.m., ED Director #3 verified that the expected frequency for taking vital signs in the ED was listed in the facility policy called Assessment, Reassessment, Vital Signs and Documentation of Patient Care. ED Director #3 stated other times nursing staff would be expected to reassess vital signs would be if the patient status declined and after pain medications were given.

iv. In an interview with ED Physician #4 on 4/18/23 at 1:35 p.m., ED Physician #4 stated prior to discharging a patient he would review the patient's vital signs and test results and visit with the patient. Further, ED Physician #4 said if vital signs were not within normal limits, the patient may have needed more testing or imaging done.