HospitalInspections.org

Based on medical record review and staff interview the facility failed to properly assess /reassess and initiate appropriate interventions to evaluate patient outcome in one (#1) of nine sampled patients.

Findings include:

Review of Patient #1's medical record reveals that the patient arrived to the progressive care unit (PCU) on 01/09/2021 at 10:54 PM, status post Open approach Inspection of Lower Vein for possible Kidney transplant (surgery). Further review of Patient #1's Medical record reveals that the Blood pressure (BP) on arrival was 156/99 with a heart rate (HR) of 117. An extensive review of the Patient's clinical record failed to show that the doctor was notified of the elevated BP and HR. No interventions were found in Patient #1's medical record in an attempt to reduce the BP and HR or find the cause of elevation. No reassessment was found in the record that the BP and HR came down. Patient #1's medical record reveals the nurse went to get a second set of vital signs at 5:15 AM and found the patient without a pulse.

Interview with the Director of Critical Care on 02/11/2021 at 9:00 AM confirmed the above findings.