HospitalInspections.org

Based on record review and interview, nursing staff failed to ensure that vital signs were obtained and recorded for 1 of 10 patients (patient #1) reviewed on this survey. Findings are:

-Review of the patient #1's medical record completed on 3/20/2023 indicated nursing services staff did not document vital signs upon presentation to the emergency department triage on 4/22/2023 at 4:41 pm. The first vital signs done on the index patient was documented at 8:00 pm: BP 146/81, HR 91, R 16, Pulse Ox 100%.

The Director of Hospital Regulatory Affairs was interviewed on 3/27/2023 at 10:30 am. She confirmed the vital signs at triage had not been documented.

It is the expected standard of practice that vital signs will be completed at triage.

-Review of the hospital policy, on 3/20/2023, "Organization-Wide Plan for Patient Assessment and Reassessment" last revised 3/1/2022 under Emergency Services Section 4(c) Vital signs- will be completed by the triage nurse or primary nurse.

Based on record review and interview, nursing and medical staff did not document a reassessment of patient #1 after her fall in the emergency department on 4/22/2022 at approximately 9:00 pm.

-Review of patient #1's medical record completed by the State Agency (SA) on 3/20/2023 revealed neither the physician or primary nurse documented a reassessment of this patient post fall.

-The Director of Hospital Regulatory Affairs was interviewed on 3/27/2023 at 10:30 am. She confirmed the reassessments by the nurse and provider had not been documented.

It is the expected standard of practice that reassessments are performed when there is a change in a patient's condition.

Review of the hospital policy "Organization-Wide Plan for Patient Assessment and Reassessment" last revised 3/1/2022 under Emergency Services Section 6 (a) Reassessments performed by RN(s), physicians and/or Mid-level providers should be completed when there is a change in the patient's condition.