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Based on interview and record review, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care (reassessments) of 1 of 10 sample patients (SP) #1.

Findings include:

The ED records showed that sample patient (SP) #1 was brought in to the Emergency Department (ED) via ambulance on 12/20/17. On 12/20/2017 at 7:46pm, a lumbar puncture was performed in the ED.

Review of SP#1 ED physician's orders showed on 12/20/17 at 2:00 PM to perform vital signs every 2 hours for 6 hours. On 12/20/17 at 2:11 pm the orders showed neuro checks and vital signs every 30 minutes, and to keep patient on bed rest.

It is noted on SP#1 Flowsheet Print Request provided by the Director of Quality on 1/31/18 at 11:00 am, and in the medical record the following on 12/20/2017: At 12:08pm, SP#1 Pulse 133, Respirations 20, Blood Pressure (BP) 130/75. At 1:13 pm, vital signs showed Temperature 38.5, Pulse 144, Respirations 16, BP 145/63. At 6:00 PM, vital signs were BP-114/70, Pulse 113, and Respirations 20. At 6:37pm, vital signs showed Pulse 123, Respirations 20, and BP- 102/61.

The record did not show evidence that the vital signs were monitored every 2 hours, and the neuro check assessed every 30 minutes and documented as ordered. It is further noted that there was no evidence of monitoring and periodic reassessments of SP#1 with an acuity level of Emergency Severity Index (ESI) at level 2. Further review did not show evidence of a pre and a post lumbar puncture care, monitoring, and patient/family instructions.


The Policy "Nursing Assessment and Reassessment of Patients", Revised date 03/21/2017, (pg. 8) Section N: ED Reassessment, showed that patients are reassessed based upon the triage acuity, and nursing care is evaluated on a continual basis to determine the progress or pt. lack of progress. Reassessment is documented. Reassessment shall include the pt. and goals, recheck of any abnormal vital signs, any change of status and that there is no change in status from previous assessment. The facility failed to follow their own policy.

Interview on 1/31/18 at 10:54 am with the ED Nursing Director revealed that patients assigned with acuity level of ESI 2 are checked every 2 hours or more often as needed for vital signs, assessments, and to evaluate patient care and then documented in the medical records.

Interview of Staff G on 02/01/18 at 9:44 am who was assigned to SP#1, recalls taking report from Staff D (the morning shift nurse). The pt. had a lumbar puncture, and recalls he told the pt. to lay flat and recalls pt. to be stable.

Interview of Staff D on 1/31/18 at 2:44pm revealed that she recalls SP#1 and stated that patient assessment and assigning of triage level, assessment and reassessment, and monitoring based on the pt. needs and by the ESI level assigned. She noted that for pts's assigned with ESI 2, she checks vital signs and reassess the patients every 2 hours and at times more frequent than 2 hours, and documents.