HospitalInspections.org

A. Based on document review and interview, it was determined that for 3 of 4 patients (Pts. #1, #2. and #4) reviewed for monitoring, the Hospital failed to ensure that patients' vital signs were performed as required.

Findings include:

1. The Hospital's policy titled, "Frequency of Vital Signs" (dated 5/17/2022), was reviewed and required, "...Daily vital signs are performed according to unit routines. The frequency of vital signs may vary according to the physician's order or done in greater intervals based on individual needs and the nurse's assessment. Routine vital signs are performed at the following frequency in the following units: ... c. Telemetry units: every 4 hours..."

2. The clinical record of Pt. #1 was reviewed on 9/25/2023. Pt. #1 presented to the emergency department (ED) on 5/10/2023 at 3:34 PM with a complaint of generalized weakness. Pt. #1 was admitted to 4 west, neuro - telemetry unit on 5/10/2023 at 8:48 PM. Physician's orders for vitals signs indicated to follow unit rountine (every 4 hours per policy). Vital signs were taken on Pt. #1 every 4 hours while Pt. #1 was on the telemetry unit with the following exceptions:
5/11/2023 - 9:01 AM to 4:01 PM (7 hours)
5/11/2023 - 8:01 PM to 5/12/2023 6:01 AM (10 hours)
5/13/2023 - 7:01 PM to 5/14/2023 1:01 AM (6 hours)
5/14/2023 - 8:01 AM to 2:01 PM (6 hours)
5/18/2023 - 7:01 PM to 5/19/2023 5:01 AM (10 hours)
5/20/2023 - 9:01 AM to 7:01 Pm (10 hours)
5/21/2023 - 9:01 AM to 5:01 PM (8 hours)
5/22/2023 - 1:01 PM to 801 PM (7 hours)
5/22/2023 - 11:01 PM to 5/23/2023 5:01 AM (6 hours)

3. The clinical record of Pt. #2 was reviewed on 9/25/2023. Pt. #2 was admitted on 9/19/2023 to the Neuro Telemetry Unit, with a diagnosis of seizures. Physician's orders for vitals signs indicated to follow unit rountine (every 4 hours per policy). Vital sign flowsheets from 9/20/2023-9/25/2023 were reviewed and lacked documentation of a full set of vital signs every 4 hours as required between the following dates/times:
- 9/20/2023 7:48 AM to 1:45 PM (5 hours and 57 minutes)
- 9/21/2023 3:08 AM to 9:49 AM (6 hours and 41 minutes)
- 9/21/2023 8:14 PM to 9/22/2023 5:38 AM (9 hours and 24 minutes)
- 9/22/2023 9:02 PM to 9/23/2023 5:41 AM (8 hours and 39 minutes)
- 9/23/2023 9:40 PM to 9/24/2023 4:30 AM (6 hours and 50 minutes)

4. The clinical record of Pt. #4 was reviewed on 9/25/2023. Pt. #4 was admitted on 9/21/2023 to the Neuro Telemetry Unit, with a diagnosis of acute encephalopathy (disorder of the brain). Physician's orders for vital signs indicated to follow unit routine (every 4 hours per policy).Vital sign flowsheets from 9/21/2023-9/25/2023 were reviewed and lacked documentation of a full set of vital signs every 4 hours as required between the following dates/times:
- 9/21/2023 5:30 PM to 9/22/2023 5:33 AM (12 hours and 3 minutes)
- 9/23/2023 9:02 AM to 4:42 PM (7 hours and 40 minutes)

5. An interview was conducted with the 4 Main Supervisor (E#3) on 9/25/2023, at approximately 12:30 PM. E#3 stated that for the telemetry unit(s), a full set of vital signs (including but not limited to temperature, blood pressure, heart rate, and respirations) are taken every 4 hours, unless a different frequency is ordered by a physician. E#3 reviewed the electronic medical records for Pts. #2 and #4 and stated that there were gaps in the vital sign documentation. E#3 could not find any documentation in the record to indicate why the vital signs were missed during those periods.


B. Based on document review and interview, it was determined that for 2 of 4 patients (Pts. #2 and #4) reviewed for feeding assistance and/or intake monitoring, the Hospital failed to ensure that patients' nutritional intake were monitored and feeding assistance provided as needed.

Findings include:

1. The Hospital's policy titled, "Patient Care Planning" (dated, 4/27/2023), was reviewed and required, "...The plan of care is informed by the patient's goals of care and includes time frames, settings, and services required to address those goals... The registered nurse or care provider, in collaboration with the patient's interdisciplinary team, initiates the patient's plan of care... Nursing reviews and documents progress toward goals and outcome summary at a minimum of every shift..."

2. The clinical record of Pt. #2 was reviewed on 9/25/2023. Pt. #2 was admitted on 9/19/2023 to the Neuro Telemetry Unit, with a diagnosis of seizures. The Nursing Care Plan, dated 9/20/2023, included, "Promote and Optimize Oral Intak... Assess for adequate oral intake, if inadequate, offer oral supplemental food or drinks to enhance calorie and protein intake... Assess need and assist with meal set-up and feeding..." A Dietician's Note, dated 9/23/2023 included, "...Diet order: mechanical soft diet - poor to fair intake... Risk of malnutrition... Recommendation/Plan/Goals: - encourage and monitor intake... Goal: tolerate >75% of most meals..." Nursing flowsheets from 9/19/2023-9/25/2023 were reviewed and lacked documentation of meal intake on 9/21/2023 and 9/23/2023.

3. The clinical record of Pt. #4 was reviewed on 9/25/2023. Pt. #4 was admitted on 9/21/2023 to the Neuro Telemetry Unit, with a diagnosis of acute encephalopathy (disorder of the brain). The Nursing Admission Assessment, date 9/21/2022 at 4:30 PM, indicated that Pt. #4 was a total feed (needs assistance with feeding). The Nursing Care Plan, dated 9/22/2023, include, "Optimize Eating and Swallowing... Assess need and provide assistance with meal set-up and feeding, encourage use of adaptive equipment, if applicable..." Nursing flowsheets from 9/21/2023-9/25/2023 reviewed and lacked documentation of meal intake and that feeding assistance was provided for 1 of 3 meals on 9/21/2023, 9/22/2023, and 9/23/2023; and for all meals on 9/24/2023.

4. An interview was conducted with the 4 Main Supervisor (E#3) on 9/25/2023, at approximately 12:30 PM. E#3 stated that patients are provided 3 meals a day. E#3 stated that there should be some documentation of the meal intake and whether assistance with meals was provided. E#3 stated that if the patient refuses or is unable to eat (i.e lethargic), the staff should document the reason in the record and that an attempt was made. E#3 was not able to find documentation as to why intake amounts were missing on the dates and times mentioned.