HospitalInspections.org

Based on interview and record review, the facility failed to ensure that nursing notes regarding post-surgical vital signs were accurate in the monitoring of the patient's condition for 1 of 5 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient underwent surgery on 8/24/10. The heart rate and blood pressure readings (shown respectively, below) for the patient during her pre-operative period on 8/24/10 were as follows: 2:52 PM - 64 - 108/71; 1:50 PM - 66 - 108/72; and 1:55 PM - 63 - 108/69. The patient entered the Operating Room at 2:02 PM. The last four heart rate and blood pressure readings while in the recovery room were as follows: 7:15 PM - 59 - 89/50; 5:30 PM - 67 - 86/49; 5:45 PM - 57 - 83/46.

An entry was made in the REACT Scoring System in the medical record at 6:18 PM. It indicated a level of "2" (meaning a requirement was met) for the following: "Systolic blood pressure is at pre-op resting level or higher and the radial and ulnar pulses are strong." The reference in this statement to the blood pressure reading was inaccurate, as revealed when evaluating the pre-op readings as shown above. In these readings, systolic was at 108. None of the last four recovery room systolic readings read that level. During an interview with the Assistant Nurse Manager on 12/28/10 at 12:45 PM, she confirmed that she could not find a reading in the record which would have fulfilled the requirements of this statement.