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Based on interview and document review, the hospital failed to ensure post-operative vital sign monitoring were performed and documented as ordered by the provider or as indicated in the hospital policy titled Patient Outcome Standard for 5 of 10 patients (P33, P35, P36, P37, P38) who were reviewed for post-operative care following a surgery or procedure.

Findings include:

P33's medical record review indicated P33 was admitted on 6/2/25, with concerns of incarcerated ventral umbilical hernias. On 6/2/25, P33 underwent an exploratory laparotomy, right hemicolectomy with ileotransverse anastomosis, strangulated hernia repair with Vicryl mesh underlay.

P33's medical record revealed P33 had orders for standard post-operative vital signs and left the post-acute recovery unit (PACU) on 6/2/25 at 6:53 p.m.

P33's vital signs were documented as follows:
-6/2/25 at 7:02 p.m., blood pressure 99/57, heart rate 96, respirations 16, oxygen saturation 98%
-6/2/25 at 7:06 p.m., blood pressure 93/72, no heart rate, respiration, or oxygen saturation were documented
-6/2/25 at 8:43 p.m., blood pressure 92/66, heart rate 95, respiration 16, oxygen saturation 98%

On 9/17/25 at 4:03 p.m., RN-B verified P33's the post-operative vital sign monitoring was not completed and verified documentation of the 15-minute vital signs were missing as well as the hourly vital signs. RN-B stated the documentation showed P33 was hypotensive, and she would have expected more frequent vital sign monitoring.

On 9/17/25 at 4:43 p.m., RN-C verified they would have expected the nurse to follow the standard for post-operative vital sign monitoring for P33 and stated close post-operative vital sign monitoring was important to watch for complications, for example post-operative bleeding. RN-C stated the goal was to intervene before an emergency occurred. RN-C verified respirations were part of post-operative vital sign monitoring.

P37's medical record review indicated P37 was admitted on 9/3/25 with malignant neoplasm of the ascending colon and right renal mass for a planned surgery.

On 9/3/25, P37 underwent laparoscopic assisted ascending colectomy and right robotic assisted laparoscopic radical nephrectomy with adrenal sparing.

P37's medical record identified they arrived on the nursing unit at 8:09 p.m., with orders for standard post-operative vital signs.

P37's vital signs were documented as follows:
-9/3/27 at 8:09 p.m., blood pressure 123/71, heart rate 87, respirations 18, oxygen saturation 89%
-9/3/27 at 8:30 p.m., blood pressure 132/70, heart rate 89, respirations were not documented, oxygen saturation was not documented
-9/3/25 at 8:45 p.m., blood pressure 113/66, heart rate 87, respirations were not documented, oxygen saturation 96%
-9/3/25 at 9:00 p.m., blood pressure 112/68, heart rate 85, respirations were not documented, oxygen saturation 97%
-9/4/25 at 3:06 a.m., blood pressure 136/69, heart rate 82, respirations 14, oxygen saturation 95%

On 9/17/25 at 3:35 p.m., RN-B verified the standards for post-operative vital sign documentation was not followed for P37. RN-B verified documenting respirations was important to ensure the patient was oxygenating properly. RN-B verified there was not follow up for an oxygen saturation that was low at 89%.

On 9/17/25 at 4:52 p.m., RN-C verified P37's the documentation did not meet the standard of care for post-operative vital sign monitoring.

P38's medical record review indicated P38 was admitted on 9/5/25 with symptoms of small bowel obstruction such as abdominal pain, distention, nausea.

On 9/5/25, P38 underwent laparoscopic assisted small bowel resection. P38 arrived on the post-operative nursing unit on 9/5/25 at 8:57 p.m., with orders for standard post-operative vital signs.

P38's vital signs were documented as follows:
-9/5/25 at 9:15 p.m., blood pressure 153/67, heart rate 65, respirations were not documented, oxygen saturation 97%.
-9/5/25 at 9:30 p.m., blood pressure 136/122, heart rate 62, respirations 18, oxygen saturation 95%
-9/5/25 at 9:45 p.m., blood pressure 149/60, heart rate 67, respirations were not documented, oxygen saturation 97%.
-9/5/25 at 11:37 p.m., blood pressure 128/60, heart rate 71, respirations 16, oxygen saturation 98%
-9/6/25 at 4:22 a.m., blood pressure 148/58, heart rate 68, respirations 16, oxygen saturation 96%

On 9/17/25 at 3:53 p.m., RN-B verified the documentation for P38 did not meet the standard of care for post-operative vital sign monitoring, and stated the documentation was missing respiration rates, missing hourly checks, and did not have documentation for an elevated blood pressure re-check.

On 9/17/25 at 4:53 p.m., RN-C verified the documentation for P38 did not meet the standard of care for post-operative vital sign monitoring. RN-C stated there seemed to be a gap in knowledge and stated if documentation was not documented it was considered "not done".

P35's medical record review indicated P35 was admitted on 9/6/25 with right upper quadrant abdominal pain was diagnosed with cholelithiasis, elevated LFTs (liver function tests), and dilated bile duct concerning for possible choledocholithiasis.

On 9/7/25, P35 was taken to surgery for laparoscopic cholecystectomy with intraoperative cholangiogram. P35 arrived on the post-operative nursing unit on 9/7/25 at 5:16 a.m., with orders with orders for standard post-operative vital signs.

P35's vital signs were documented as follows:
-9/7/25 at 5:16 a.m., blood pressure 149/107, heart rate 72, respirations 18, oxygen saturation 100%
-9/7/25 at 6:00 a.m., blood pressure 141/103, heart rate 72, respirations were not documented, oxygen saturation 98%.
-9/7/25 at 3:20 p.m., blood pressure 148/92, heart rate 70, respirations were not documented, oxygen saturation 98%.

On 9/18/25 at 3:11 p.m., RN-B verified the post-operative vital sign standard was not followed for P35. RN-B verified she would have expected follow up on the blood pressures and a documented call to the provider if the blood pressures did not improve.

On 9/18/25 at 4:49 p.m., RN-C verified the post-operative vital sign standard was not followed for P35. RN-C stated they would have expected more frequent monitoring of the blood pressure based on what had been documented.

P36's medical record review indicated P36 was admitted on 9/11/25 for a planned surgery for laparoscopy-assisted abdominal wall hernia repair with mesh. On 9/11/25 at 10:06 a.m., P36 left the PACU. P36 had orders for standard post-operative vital signs.

P36's vital signs were documented as follows:
-9/11/25 at 10:15 a.m., blood pressure 116/76, heart rate 93, respirations were not documented, oxygen saturation 91%.
-9/11/25 at 10:30 a.m., blood pressure 108/84, heart rate 87, respirations were not documented, oxygen saturation 93%.
-9/11/25 at 10:45 a.m., blood pressure 115/80, heart rate 86, respirations were not documented, oxygen saturation 91%.
-9/11/25 at 3:50 p.m., blood pressure 101/69, heart rate 91, respirations 18, oxygen saturation 95%

On 9/18/25 at 2:52 p.m., RN-B verified the standard for post-operative vital sign monitoring for P36 had not been followed. RN-B verified the potential was there to miss an opportunity to intervene.

On 9/16/25 at 3:58 p.m., Doctor of Osteopathic Medicine (DO)-A stated it was important to monitor vital signs after a procedure or surgery because might see changes in the vital signs to indicate post-operative complications for example bleeding.

On 9/17/25 at 9:10 a.m., RN-D stated the standard for post-operative vital sign monitoring was every 15 minutes times four, every 30 minutes for one hour, and then every four hours.

On 9/17/25 at 9:27 a.m., RN-E stated the standard for post-operative vital sign monitoring was every 15 minutes times four, every 30 minutes times two, then every hour.

On 9/17/25 at 9:53 a.m., RN-F stated she was not sure what the standard for post-operative vital sign monitoring was but stated it was "programmed into the machine". Not able to state the frequency to check and validate the readings.

On 9/17/25 at 10:00 a.m., RN-G stated the standard for post-operative vital sign monitoring was every 15 minutes times three, every 30 minutes times two, every hour once or twice.

On 9/17/25 at 10:07 a.m., RN-H stated the standard for post-operative vital sign monitoring was "in the computer". Not able to state the frequency to check and validate the readings.

On 9/17/25 at 10:20 a.m., RN-I stated the standard for post-operative vital sign monitoring was programed into the "monitor". RN-I was not able to state the frequency to check and validate the readings. RN-I stated it was their understanding the machine measured the vital signs and the vital sign readings would flow into the medical record whether they were "validated" or not.

On 9/17/25 at 11:15 a.m., RN-B stated there was a concern when a machine was doing the work (measuring the vital signs), the nurses might not be reviewing the vital signs in real-time, although she verified it was her expectation they would review the vital signs in real-time to see complications and act on them timely.

On 9/18/25 at 2:12 p.m., the chief nursing officer (CNO) verified she would expect nurses to document in real time as much as possible. The CNO verified this was important to monitor for potential complications following the surgery or procedure. The director of nursing (DN) verified monitoring post-operative vital signs was important to look for trends, detect deterioration, and to be able to intervene as soon as possible.

On 9/18/25 at 4:51 p.m., RN-C verified the standard for post-operative vital sign monitoring had not been followed reviewing what had been documented in the electronic medical records.

The hospital policy titled Patient Outcome Standards: Medical 1, Medical 2, Medical Oncology, Neuroscience/Spine, Orthopedics, Surgical Care 1, and Surgical Care 2 Units dated 6/2025, indicated the purpose of the policy was to identify outcome standards (goals) and process standards (interventions) for patients. Patients outcomes/goals included the ability for patients to maintain hemodynamic and respiratory stability and afebrile. Process standards/interventions included a full set of vital signs which included blood pressure with mean arterial pressure (MAP), pulse, respiratory rate (RR), oxygen saturation including oxygen source and amount (O2 saturation), and temperature is measured on arrival and every 4 hours for the first 24 hours (0400, 0800, 1200, 1600, 2000 and 2400). Then if stable four times daily or more often as clinically indicated. Post invasive procedure without sedation vital signs (procedures can include chest tube insertion, liver biopsy, thoracentesis, paracentesis): On arrival to unit: full set; Every 15 minutes x 3, every 30 minutes x 2, every 60 minutes x 1: BP with MAP, pulse, O2 saturation.Every 4 hours: full set; or per provider order then every 4 hours. Post-op (following discharge from PACU or Phase 2 recovery) vital signs: On arrival to unit: full set; Every 15 minutes x 2, then every 60 minutes x 2: BP with MAP, RR, pulse, O2 saturation; every 4 hours: full set x 24 hours. Assess rate and regulatory of pulse on arrival and twice per day and as clinically indicated. Assess regularity, effort, and lung sounds on arrival, twice per day and as clinically indicated. Attempt to wean oxygen every 4 hours, while awake and more often as clinically indicated. Patients will be encouraged to cough and deep breathe every 2 hours while awake.

Clinical Documentation dated 8/2025, identified "A comprehensive accurate EHR (electronic health record) will be maintained" and "Documentation will be done concurrently or as soon as possible (recommended within 60 minutes)."