HospitalInspections.org

Based on policy and procedure review, medical record review and staff interview, the facility staff failed to obtain vital signs per physician orders for 1 of 4 patients with a stroke (Patient #2).

The findings include:

Review on 06/26/2019 of a policy titled "Standardized Vital Signs Adult" last revised 12/20/2017, revealed "...C. The following will identify a minimum frequency of vital signs of the hospitalized, adult patient unless otherwise indicated. More frequent vital signs may be indicated by physician order, patient condition, procedure or policy ..."

Closed medical record review on 06/25-26/2019 of Patient #2, revealed a 77-year-old male admitted on 04/21/2019 for a stroke. Review of the physician orders dated 04/21/2019 at 0218, revealed "Vital Signs Every 4 Hours." Review of the vital sign flowsheet revealed vital signs documented on 04/21/2019 at 2009. Review of the next available documentation for vital signs was at 0414 (8 hours and 5 minutes after the previous vital signs). Review of the next available documentation for vital signs was at 1105 (6 hours and 51 minutes after the previous vital signs). Review of the vital sign flowsheet revealed vital signs were taken on 04/23/2019 at 0716. Review revealed no other documented vital signs after 0716. Review revealed Patient #2 was discharged on 04/23/2019 at 1459.

Interview on 06/26/2019 at 1330 with RN #1 (Registered Nurse), revealed she discharged Patient #2 on 04/23/2019. Interview revealed vital signs were normally done every 4 hours or every 8 hours on the unit. Interview revealed it also depended on the physician orders. Normally the nursing assistant got vital signs and the nurse ensured they had been documented. Regarding why Patient #2 did not have vital signs after 0716 on 04/23/2019, RN #1 stated "guess that was overlooked."

Interview on 06/26/2019 at 1540 with CNA #1 (Certified Nursing Assistant), revealed she took care of Patient #2 on 04/21/2019, on the 7pm to 7am shift. Interview revealed normally the nursing assistants got vital signs for patients. Interview revealed patients vital signs would be taken either every 8 hours or every 4 hours on the unit. Regarding why there were no vital signs documented for Patient #2 on 04/21/2019 around 11pm, CNA #1 revealed "that would be a mistake."

Interview on 06/26/2019 at 1500 with Nurse Manager #1, revealed normally nursing assistants got patient's vital signs and the nurse should be checking to ensure they were documented. Interview revealed physician orders should be followed for how often vital signs needed to be checked. Interview revealed Patient #2's vital sign order frequency was every four hours, therefore, vital signs should have been checked and documented every four hours.

NC00151634