HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient was monitored as ordered by a physician for 4 of 10 patients with such orders [Patients #5-8].

Findings were:

Physician order sets for Clonidine and Buprenorphine Opioid Protocols included the following:

Clonidine Opioid Protocol on 6/5/22 at 11:00 a.m. included the following physician order:
"Vital Signs: Take and Record Temperature, Pulse, Respiratory Rate and Blood pressure every 4 hours For first 96 hours, then every 8 hours for 72 hours, then daily thereafter ..."

Buprenorphine Opioid Dependence Protocol on 6/6/22 at 9:30 a.m. included:
"Vital Signs: Take and record Temperature, Pulse, Respiratory Rate and BP every 4 hours for the first 96 hours; must ask the provider for discontinuation of the order if vital signs are stable ..."

A review of 10 patient records with these orders revealed 4 of the 10 patients [Patients #5-8] did not have vital signs documented every 4 hours as ordered.

For example, Patient #6 had a Buprenorphine Opioid Dependence Protocol order on 6/10/22 at 8:30 a.m. The vital sign order was not discontinued. The vital signs for Patient #6 were taken on 6/10/22 at 9:00 a.m. and then at 4:00 p.m. They were not documented again until 6/11/22 at 4:00 a.m., then again at 10:00 a.m. and 8:00 p.m. They were not charted again until 4:00 a.m. on 6/12/22.

Patient #8 had the protocol ordered on 6/8/22 at 8:00 p.m. The vital signs order was not discontinued. Vital signs were documented for Patient #8 on 6/9/22 at 6:00 a.m., 8:30 a.m., then not again until 4:00 p.m. They were not again documented until 6/10/22 at 4:00 a.m., then at 9:00 a.m., then at 8:00 p.m. They were documented next on 6/11/22 at 10:00 a.m., then at 8:00 p.m.

In an interview with Staff #2, hospital chief nursing officer, on 6/28/22 at 4:25 p.m., in the administrative conference room, she stated, "We know we have a problem with consistency with vital signs. We know we need to address it ..."