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SISTERS OF CHARITY HOSPITAL
EMERGENCY SERVICES POLICIES
Tag No.: A1104
Based on policy review and medical record review, the facility does not ensure Emergency Department (ED) patients vital signs are reassessed in accordance with facility policy in 3 of 30 patients (Patients #26, #27 and #29).
Findings include:
Review on 12/11/18 of policy #ED-05 Emergency Department Standards of Care, revealed frequency of reassessment is determined by triage level. Vitals signs should be reassessed at a minimum of every 2 hours for triage levels of 1, 2 and 3.
Review on 12/11/18 of ED medical records revealed Patients # 26, 27 and 29 presented to the ED on 10/22/18 and were assigned a triage level of 3. For Patient #26 initial vital signs were obtained at 01:03 PM and not repeated until 08:25 PM. For Patient #27 initial vital signs were obtained at 04:16 PM and not repeated until 08:19 PM. For Patient #29 initial vital signs were obtained at 07:37 PM and not repeated until 10/23/18 at 01:11 AM.
Interview on 12/11/18 at 01:00 PM with Staff (D), RN Quality and Patient Safety confirmed these findings.