HospitalInspections.org

Based on staff interview, medical record review and facility policy review and education, the hospital failed to comply with 489.24 by not following facility policy and completing vital signs for six (6) hours and 49 minutes while waiting for room placement on one (1) out of 20 patient charts reviewed, Patient #1.

Findings Include:

Cross refer to A-2406 for findings.

Based on staff interview, medical record review, facility policy, and education information, the hospital failed to monitor vital signs for six (6) hours and 49 minutes while in the Emergency Department (ED), waiting for an exam room, for one (1) out of 20 patient charts reviewed, Patient #1.

Findings Include:

MEDICAL RECORD REVIEW

Review of Medical Record for Patient #1 revealed that the patient entered the facility ED with chief complaint of worsening back pain to the left upper back, fever, and mild shortness of breath on 10/19/2021 at 4:41 p.m. Triaged was completed by the Nurse Practitioner (NP) as a level three (3) at 5:01 p.m. Testing was ordered and initiated. After testing, Patient #1 was sent to the lobby to wait for an open ED exam room. Patient #1 had an encounter at 6:06 p.m. on 10/19/2021 for vital signs by a medical technician. The next patient encounter documented in the Medical Record was at 12:55 a.m., 10/20/2021 by a Registered Nurse (RN). Review of the medical record revealed the patient was waiting in the lobby for ED room placement during this time.

INTERVIEWS

During an interview at 9:15 a.m. on 11/16/2021, the Administrative Nursing Director of ED confirmed the ED was very busy on 10/19/2021 and there were no open rooms. Administrative Nursing Director of the ED reported that between the hours of 6:00 p.m. to 12:00 a.m., the ED lobby averaged 28 patients per hour waiting for ED beds and Level 3 acuity beds averaged 40 patients per hour.

During an interview at 3:30 p.m. on 11/16/2021, RN #1, confirmed being the triage nurse on the day shift on 10/19/2021 and remembered the ED beds were full, and Patient #1 waited in the ED lobby. RN #1 reported that the flow of the ED is for the nurse to triage the patient and then the patient goes to the next triage room where the Nurse Practitioner (NP) performs the Medical Screening Exam (MSE). RN #1 reported that they try to complete any ordered blood work or other orders at this time before they send them back to the lobby if there are no available rooms to put them in. RN #1 reported that when patients must stay in the lobby there are techs assigned to the lobby to do their vital signs and monitor the patients.

During an interview on 11/16/2021 at 3:40 p.m. with medical technician (med tech) #1, it was revealed that she reported off to the next lobby med tech on 10/19/2021, but she could not remember who the oncoming tech was that night.

During an interview on 11/16/2021 at 3:45 p.m. the Project Analysis Nurse, confirmed there was no documentation in Patient #1's chart showing anyone checked on or performed vital signs check on Patient #1 on 10/19/2021 from 6:06 p.m. to 12:55 a.m. 10/20/2021.

During an interview on 11/17/2021 at 9:55 a.m., the Patient Care Coordinator (PCC), revealed she did not remember the patient, but she reported that if it wasn't charted then it wasn't done. PCC reported that she did remember 10/19/2021 and that they were very busy and did not have enough rooms and were having to leave patients in the lobby until a room became available.

During an interview on 11/17/2021 at 10:05 a.m. with RN #2, the triage nurse for the night shift, it was revealed that she did remember that Patient #1 came in with his wife 10/19/2021. RN#2 reported that the wife stopped her at 12:55 a.m. on 10/20/2021 and asked her about an age discrepancy in his IRIS account (which is an online medical record portal for patients). RN #2 reported that the patient asked if this is why he had not been moved back to a room. RN #2 reported that she assured them both that it was not and that the ED rooms were all full and as soon as one opened, he would be moved back. RN #2 reported that both the patient and the wife were satisfied at this time.

During an interview on 11/17/2021 at 10:15 a.m., RN #3, revealed taking over care of the patient around 1:30 a.m. 10/20/2021 when the patient was brought to a bed that became available. RN #3 reported the wife left and went home when he brought the patient back to a room. RN #3 reported that the wife called often throughout the night to check on the patient. RN #3 reported that the patient had computerized tomography (CT), (a diagnostic procedure which uses scans of the body with X-rays and computer to see images in the body), magnetic resonance imaging (MRI) (a diagnostic test using a machine with magnetic fields and computer to take images of the body), and multiple lab tests and that all the tests including the labs did not show anything indicative of needing to be admitted. RN #3 reported that the patient's white blood count (WBC) was normal, he did have an increased C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) (lab tests that can show inflammation in the body) but they were not alarming enough to admit the patient per the Medical Doctor (MD). RN #3 reported that MD went in and explained all the test results to the patient in detail. RN #3 reported that he called the patient's wife to come pick him up for discharge and answered all her questions about test results. RN #3 reported that the patient and the wife seemed satisfied with the care the patient received and did not voice any complaints to him.

During an interview on 11/17/2021 at 10:25 a.m. with Tech #2, it was revealed that he did not remember this patient at all or anything about him. Tech #2 reported that he remembered that 10/19/20201 was very busy.

During a telephone interview on 11/17/2021 at 2:40 p.m. with Tech #3, it was revealed that he was assigned to the lobby on 10/19/2021, the night of the complaint. Tech #3 reported that he did not remember the patient. Tech #3 reported that when he works the lobby, he checks vital signs every two (2) hours just like when he works in the back. Tech #3 reported that if he doesn't have time to document the vitals then he usually passes them off to someone else to document for him.

During an interview on 11/17/2021 at 2:45 p.m. the Administrative Nursing Director of the Emergency Department, confirmed Patient #1 should have had vital signs every 2 hours and rounded on every hour, even if he was in the lobby. Administrative Nursing Director of ED reported that he would have expected the medical technicians (techs) and the Nursing staff to do vital signs every 2 hours and round every hour as they are taught in all the education provided to them in staff meetings.

During an interview on 11/17/2021 at 4:50 p.m. the Administrative Nursing Director of Operations confirmed that she expected the ED staff to round on the patients every hour and document vital signs every two (2) hours as they are taught in their staff education meetings.

POLICY

Review of facility policy entitled "Department of Emergency Services ...Vital Signs Guidelines ..." (Updated 5/8/2017) revealed " ...1. Vital signs should be assessed on admission to the Emergency Department. 2. Vital signs should be reassessed as indicated by the condition of the patient and within 30 minutes of discharge on all patient with an acuity of 1, 2, and 3 ...".

Review of facility educational power point (no date noted) provided by the Administrative Nursing Director of Operations (ANDOO) revealed ..."Vital signs" ... " ...Techs will be assigned daily to check vital signs on the EVEN hours, Look for vital sign assignments on your shift schedules ...", "Patient Encounters" ..."Nurses must round on patients every 45 minutes to 1 hour to address needs and provide updates: Pain, Plan of Care, Duration ...ALL staff may round on patients and answer call lights. 'Warm and Fuzzy', Document in EPIC when you round on patients ...".

Patient #1 did not receive an appropriate and on-going medical screening examination as he did not have vital signs performed for almost sever hours of his hospital stay per hospital policy.