HospitalInspections.org

Based on record reviews, staff interviews and policy review the facility failed to ensure patient's received adequate reassessment prior to discharge from the Emergency Department in accordance with the hospital assessment policy for 2 of 5 sampled patients. (#1 and 3)

The findings include:

Review of patient #1's record was conducted on 1/31/2013. The Emergency Room record revealed the patient presented to the Emergency Room on 12/1/2012 at approximately 8:22 PM after a fall. A full set of vital signs to include temperature of 98.4 F, blood pressure of 143/86, pulse of 80, respirations of 16, pain of 10, and oxygen saturation of 97% on room air was obtained on 12/1/2012 at approximately 8:30 PM. The patient was administered Lortab 5/325 mg 1 by mouth at approximately 8:39 PM and another Lortab of the same dose at approximately 9:37 PM. Lortab is a narcotic pain medication. No further vital signs, other than a pain assessment was completed and documented prior to the patient's discharge home at approximately 9:38 PM.

Review of patient #3's record was conducted on 1/31/2013. The Emergency Room record revealed the patient presented to the Emergency Room via ambulance on 12/1/2013 at approximately 8:14 PM after a fall striking the face. A full set of vital signs to include temperature of 98, blood pressure of 100/53, pulse of 77, respirations of 18, oxygen saturation of 98% on room air and pain of 5 was obtained on 12/1/2013 at approximately 8:18 PM. The patient was administered Ativan 1 mg intravenous push at approximately 8:30 PM. The nurse documentation revealed at approximately 9:40 PM on 12/1/2013 the patient was difficult to arouse with an oxygen saturation of 88.5%. Oxygen saturations below 90% are considered to be low. The nurse notified the physician. At approximately 9:55 PM the patient received Romazicon 0.05 mg intravenous push. Documentation revealed the patient is more alert at approximately 10:04 PM. No further vital signs or oxygen saturation, other than a pain assessment was completed and documented prior to the patient's discharge home at approximately 10:05 PM.


The hospital policy Assessment of the Emergency Department Patient was reviewed on 1/31/2013. The policy stated vital signs shall be assessed on all patients every 2 hours or prior to discharge. If a patient is in the Emergency Room less than one hour and has no abnormal vital signs, and did not receive any medications that could alter vital signs, such as narcotics or Vancomycin, that patient does not need discharge vital signs.

An interview was conducted with the Emergency Department Director on 1/31/2013 at approximately 2:24 PM. She stated she had no explanation for the patients' vital signs not being reassessed prior to their discharge or patient #3 not having her oxygen saturation reassessed prior to discharge.

The following is an excerpt from the U.S. National Library of Medicine at www.nlm.nih.gov:

Vital signs include the heart beat, breathing rate, temperature, and blood pressure. These signs may be watched, measured, and monitored to check an individual's level of physical functioning.