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Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by:

1. The facility failed to ensure the staff obtained a specific physician order for each episode of restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use including the type of restraint used and the indication for restraints use for one of two sampled patients (Patient 24) in accordance with the facility's policy and procedure regarding the use of restraints.

This deficient practice resulted in Patient 24 being restrained without proper physician order reflecting the type of restraint in use and the indication for restraint use, which may result in complications of improper restraint use such as dehydration, choking, skin problems, etc. (Refer to A-0168)

2. The facility failed to ensure restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) orders were renewed daily for two of 30 sampled patients (Patient 10 and Patient 13) in accordance with the facility's policy and procedure regarding renewal of orders for restraint use.

This deficient practice resulted in Patients 10 and 13 being restrained without a physician's order and indication for restraint use, which had the potential to result in improper patient restraints use and may lead to patient harm with complications such as choking, dehydration, etc. (Refer to A-0172)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on observation, interview and record review, the facility failed to ensure the staff obtained a specific physician order for each episode of restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use including the type of restraint used and the indication for restraints use for one of two sampled patients (Patient 24) in accordance with the facility's policy and procedure regarding the use of restraints.

This deficient practice resulted in Patient 24 being restrained without a proper physician order reflecting the type of restraint in use and the indication for restraint use, which may result in complications of improper restraint use such as dehydration, choking, skin problems, etc.

Findings:

During an observation on 1/24/2024 at 10:25 a.m., in Patient 24's room, with the Director of Medical Surgical (serves the general population hospitalized for various cases such as surgery, etc.) and Telemetry (a unit in the hospital where patients undergo continuous heart monitoring) Unit (DIR 7), Patient 24 was observed to have bilateral (both) wrist restraints (restraints made of foam padding applied to wrists area to restrict movement of the arms) and bilateral mittens (cloth mittens placed on the hands to restrict movement of the hands and fingers).

During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/15/2024, the H&P indicated, Patient 28 was admitted to the facility with diagnoses of cholecystitis (inflammation of gallbladder, a small, digestive organ beneath the liver) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).

During a review of Patient 24's physician order of restraints, dated 1/26/2024, the order indicated, "restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) type: bilateral mittens, bilateral wrists, vest (a jacket placed on someone to restrict body movement), and 4 bed side rails (side rails of the hospital bed were up to restrict someone from getting out of the bed)."

During a review of Patient 24's physician order titled "continuation of restraints," with dates from 1/17/2024 to 1/25/2024, the physician orders indicated, "I (the signed physician) have assessed the patient (Patient 24) and have determined that the reason for and type of restraints is unchanged." The physician order did not indicate the type of restraints being used and the indication for restraint use on Patient 24. This was validated by the Supervisor of Clinical Informatics Registered Nurse (SCIRN) during an interview.

During a review of Patient 24's restraints flowsheet (documentation for restraints indication and type of restraints used), the restraints flowsheet indicated the following:

Restraints started on 1/16/2024 at 4 p.m. with bilateral mittens, vest and 4 bed side rails

On 1/16/2024 at 8 p.m., restraint was decreased to vest and 4 bed side rails. Bilateral mittens were removed

On 1/17/2024 at 8 a.m., nurse added bilateral mittens along with vest and 4 bed side rails

On 1/17/2024 at 12 p.m., nurse added bilateral wrist restraints along with bilateral mittens, vest and 4 bed side rails

On 1/19/2024 at 8 p.m., restraint was decreased to bilateral wrists. Bilateral mittens, 4 bed side rails and the vest were not in use.

On 1/21/2024 at 12 p.m., nurse added restraint of bilateral mittens along with bilateral wrist restraints

During an interview on 1/25/2024 at 3:41 p.m. with the Supervisor of Clinical Informatics Registered Nurse (SCIRN), SCIRN stated that the nurse should have obtained a new and specific physician order when adding restraints for a patient (Patient 24). Likewise, the SCIRN stated, restraint order should reflect the type of restraints being used and the specific indication for restraint use. However, in the case of Patient 24, the type of restraints to be used were not indicated in the physician orders from 1/17/2024 to 1/25/2024. In addition, the reason for the type of restraint use was not documented in each of the physician orders from 1/17/2024 to 1/25/2024.

During a review of the facility's policy and procedure (P&P) titled, "Restraints Seclusion," dated 12/2021, the P&P indicated, "Orders for restraint use are episode specific. For a patient experiencing early release, a new order is required to re-apply the restraint when a new need is identified ... Orders contain the type of restraints device ordered, the rationale for the order, and the time frame for restraints use if less than the maximum allowed time."

Based on observation, interview, and record review the facility failed to ensure restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) orders were renewed daily for two of 30 sampled patients (Patient 10 and Patient 13) in accordance with the facility's policy and procedure regarding renewal of orders for restraint use.

This deficient practice resulted in Patients 10 and 13 being restrained without a physician's order and indication for restraint use, which had the potential to result in improper patient restraints and may lead to patient harm with complications such as choking, dehydration, etc.

Findings:

1. During an observation on 1/24/2024 at 10:25 a.m., with Registered Nurse (RN) 3, in the Medical Surgical (serves the general population hospitalized for various cases such as surgery, etc.) and Telemetry (a unit in the hospital where patients undergo continuous heart monitoring) unit, Patient 10 was observed asleep in bed and receiving oxygen via a BiPAP (Bilevel positive airway pressure, a machine that helps push air into the lungs). Patient 10 had soft restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) placed on both left and right wrists.

Concurrently, on 1/24/2024 at 10:25 a.m., Registered Nurse (RN) 3 stated Patient 10 had restraints to the wrist to prevent Patient 10 from removing her (Patient 10) oxygen tubing.

During a review of Patient 10's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/11/2024, the H&P indicated Patient 10 "was admitted to the facility for altered mental status (change in mental function) ...Patient is alert and awake but not following any commands."

During a review of Patient 10's "Flowsheets," for restraint documentation, dated from 1/15/2024 at 6:48 p.m. to 1/19/2024 at 10 a.m., the Flowsheets indicated, Patient 10 had non-violent restraints (when a restraint is used to promote healing and improve the patient's well-being as opposed to violent behavior in which the behavior places the patient at risk for injuring self or others) to the left and right wrist for repeated attempts to remove medical equipment. The Flowsheet also indicated Patient 10 was confused and unable or does not understand instructions. Patient 10's restraints were removed on 1/19/2024 at 12 p.m.

During a review of Patient 10's "Restraint Orders," the restraint orders indicated the following: 1/15/2024 at 6:47 p.m., Restraint Non-Violent Routine. There were no restraint renewal orders for 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. This finding was validated during an interview with the SIRN and the CDCI.

During a concurrent interview and record review of Patient 10's restraint orders and nursing flowsheet, on 1/25/2023 at 12 p.m., with the Senior Clinical Informatics Registered Nurse (SIRN) and the Corporate Director of Clinical Informatics (CDCI), the SIRN and CDCI stated the following:

Patient 10 was admitted to the facility for altered mental status. Patient 10 was placed on non-violent restraints to both wrists on 1/15/2024 at 6:47 p.m.

The restraints were placed because Patient 10 was confused, and the facility wanted to prevent Patient 10 from removing her IV (intravenous, in the vein) lines.

The restraints were removed on 1/19/2024 at 12 p.m.

Restraint orders should be renewed by a physician every day, after completing a face-to-face assessment. A physician assessment was required to determine whether or not Patient 10's restraints could be discontinued or continued. The SIRN and the CDCI verified there were no restraint renewal orders for 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024 despite Patient 10 having bilateral (both) wrist restraints applied on the said dates.

During an interview on 1/25/2024 at 3:42 p.m., with the Director of the Medical Surgical and Telemetry unit (DIR7), the DIR7 verified that Patient 10's restraint orders were not renewed on 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. DIR7 stated nursing staff should have contacted the physician regarding the need to renew the restraint orders. DIR7 also said the physician should conduct a face-to-face assessment in order to determine if it was still appropriate for Patient 10 to be restrained.

During a review of the facility's policy and procedure (P&P) titled, "Restraints Seclusion #PC-380," dated 12/2021, the P&P indicated, "Renewal Orders-Orders are time limited and only good through the end of the calendar day following the order date. Physicians who renew restraint orders do so after a face-to-face assessment of the patient's need to continue restraint use ..."

2. During a review of Patient 13's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/21/2023, the H&P indicated the following: Patient 13 was admitted for a brain mass (a growth of abnormal cells in the brain) and encephalopathy (a disturbance in brain function). In addition, Patient 13 had altered mental status (change in mental function).

During a review of Patient 13's nurse's notes titled, "Care Assessments," the Care Assessments indicated a non-violent (when a restraint is used to promote healing and improve the patient's well-being as opposed to violent behavior in which the behavior places the patient at risk for injuring self or others) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body): Vest Restraint was applied on 12/27/2023 at 2 a.m., and removed on 12/29/2024 at 10 p.m.

During a review of Patient 13's physician's order titled, "Continuation of Restraints," dated 12/27/2023, the order indicated "I have assessed the patient and have determined that the reason for and type of restraints is unchanged. There was no restraint renewal order for 12/28/2023 and 12/29/2023. This was confirmed by the SCIRN during an interview.

During a concurrent interview and record review of Patient 13's restraint orders and nursing flowsheet for restraint use, on 1/25/2023 at 5:45 p.m., with the Senior Clinical Informatics Registered Nurse (SIRN) and the Corporate Director of Clinical Informatics (CDCI), the SIRN and CDCI stated the following: Patient 13 had an order for non-violent restraints on 12/27/2023. Per the nursing flowsheets, Patient 13 was restrained with a vest (a jacket placed on someone to restrict body movement) from 12/27/2023 through 12/29/2023 due to confusion. The SIRN and CDCI verified that there was no restraint renewal order for 12/28/2023 and 12/29/2023 despite Patient 13 being on vest restraint during the dates of 12/28/2023 and 12/29/2023.

During a review of the facility's policy and procedure (P&P) titled, "Restraints Seclusion #PC-380," dated 12/2021, indicated, "Renewal Orders-Orders are time limited and only good through the end of the calendar day following the order date. Physicians who renew restraint orders do so after a face-to-face assessment of the patient's need to continue restraint use ..."

Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) regarding hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and cholecystitis (inflammation of the gallbladder, a small, digestive organ beneath the liver),respectively, upon admission, for two of 30 sampled patients (Patient 22 and Patient 30) in accordance with the facility's policy and procedure regarding care plan initiation.

This deficient practice had the potential to result in the delay of treatment by not identifying the patients' (Patient 22 and Patient 30) needs and risks, which may result in worsening of the patients' (Patient 22 and Patient 30) condition and prolonged hospitalization. (Refer to A-0396)

2. The facility failed to document review of the care plan and update the care plan regarding infection, every shift, for one of 30 sampled patients (Patient 16) in accordance with the facility's policy and procedure regarding updating care plans.

This deficient practice had the potential to result in worsening of infection for Patient 16 when the interventions indicated in the care plan are not being implemented and evaluated to determine Patient 16's response to the interventions. (Refer to A-0396)

3. The facility failed to ensure nursing admission assessments (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) were conducted within twenty-four (24) hours of admission and vital signs (measure basic function of the body including body temperature, blood pressure, heart rate or pulse and respiration) were checked and documented according to the appropriate level of care (from the most seriously ill to the less serious) for three of 30 sampled patients (Patients 9, 15, and 18), in accordance with the facility's policies and procedures regarding assessment, reassessment, and vital signs check.

This deficient practice had the potential for the inability to identify potential changes in patients' (Patients 9, 15, and 18) condition and can result in a delay of care, which may lead to worsening of patient condition and/or death. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review, the facility failed to:

1. Initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) regarding hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and cholecystitis (inflammation of the gallbladder, a small, digestive organ beneath the liver), respectively, upon admission, for two of 30 sampled patients (Patient 22 and Patient 30) in accordance with the facility's policy and procedure regarding care plan initiation.

This deficient practice had the potential to result in the delay of treatment by not identifying the patients' (Patient 22 and Patient 30) needs and risks, which may result in worsening of the patients' (Patient 22 and Patient 30) condition and prolonged hospitalization.

2. Document review of the care plan and update the care plan regarding infection, every shift, for one of 30 sampled patients (Patient 16) in accordance with the facility's policy and procedure regarding updating care plans.

This deficient practice had the potential to result in worsening of infection for Patient 16 when the interventions indicated in the care plan are not being implemented and evaluated to determine Patient 16's response to the interventions.

Findings:

1a. During a review of Patient 22's "Nephrology (specialty of internal medicine that concerns that study of the kidneys) Consultation," dated 12/9/2023, the Nephrology Consultation record indicated, Patient 22 was admitted to the facility with diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure [when kidneys stop working]) and plan to initiate hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) at the facility by Monday 12/11/2023.

During a review of Patient 22's "care assessment," dated 12/11/2023, the care assessment notes indicated, Patient 22 had his (Patient 22) first hemodialysis at the facility on 12/11/2023.

During a concurrent interview and record review on 1/25/2024 at 10:49 a.m. with the Senior Clinical Informatics Registered Nurse (SCIRN), Patient 22's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was reviewed. The care plan indicated a new nursing problem with "dialysis - risk for injury" was initiated on 12/13/2023. SCIRN stated that the care plan should have been initiated on the day Patient 22 was admitted which was on 12/9/2023 in preparation for the scheduled hemodialysis on 12/11/2023. SCIRN said the care plan was not initiated in a timely manner. SICRN also said the care plan needed to be implemented in a timely manner to ensure interventions were implemented to meet Patient 22's needs.

During a review of the facility's policy and Procedure (P&P) titled, "Multidisciplinary Plan of Care," dated 12/2022, the P&P indicated, "Planning for medical, nursing, and other clinical discipline(s) care, treatment, and service(s) is individualized to meet the patient's unique needs ... the plan is maintained and revised based on patient's response ...The care plan is initiated upon admission and the plan for presenting problems should be fully developed within 24 hours of admission. During the course of hospitalization, the plan should be updated as new issues arise or change in condition occur."

1b. During a review of Patient 30's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/27/2023, the H&P indicated, Patient 30 was admitted to the facility with diagnoses of cholecystitis (inflammation of gallbladder, a small, digestive organ beneath the liver).

During a review of Patient 30's face sheet (face sheet, information including patient's basic information and demographic data), dated 11/27/2023, the face sheet indicated Patient 30 was admitted to the facility on 11/27/2023 at 6:48 a.m.

During a concurrent interview and record review on 1/25/2024 at 10 a.m. with the Director of Emergency Services (DIR5), Patient 30's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was reviewed. The record indicated that the care plan regarding cholecystitis was initiated on 11/28/2023 at 11:57 a.m.

DIR5 verified that the care plan was not initiated and completed within 24 hours of admission (admission date was 11/27/2023 at 6:48 a.m.). DIR5 also said the care plan was important to ensure that appropriate interventions were implemented and the patient's (Patient 30) response to interventions were evaluated if there was a need to make changes to ensure that patient's (Patient 30) needs (such as the need to adjust the dose of pain medication to address any patient complaint of pain resulting from the diagnosis of cholecystitis) were being met.

During a review of the facility's policy and Procedure (P&P) titled, "Multidisciplinary Plan of Care," dated 12/2022, the P&P indicated, "Planning for medical, nursing, and other clinical discipline(s) care, treatment, and service(s) is individualized to meet the patient's unique needs ... the plan is maintained and revised based on patient's response ...The care plan is initiated upon admission and the plan for presenting problems should be fully developed within 24 hours of admission. During the course of hospitalization, the plan should be updated as new issues arise or change in condition occur."

2. During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/21/2023, the H&P indicated, Patient 16 was admitted to the facility on 9/20/2023 with diagnoses of altered mental status (confusion), urinary tract infection (an infection in any part of the urinary system such as the kidneys, bladder [organ in the body that holds urine], or urethra [the tube that lets the urine leave the bladder and the body]), and sepsis (a life-threatening complication of an infection).

During a review of Patient 16's "Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process)," the care plan indicated the nursing problem of infection risk was initiated on 9/20/2023 indicating the absence of infection signs and symptoms and knowledge of infection control as the outcomes.

During a concurrent interview and record review on 1/25/2024 at 10:26 a.m. with the Senior Clinical Informatics Registered Nurse (SCIRN), Patient 16's care plan was reviewed. SCIRN verified that the care plan with nursing problem of infection was not documented to have been reviewed or updated by the nursing staff on 9/21/2023 day shift, 9/21/2023 night shift, 9/22/2023 day shift, 9/22/2023 night shift, 9/23/2023 day shift, 9/23/2023 night shift, 9/24/2023 day shift and 9/24/2023 night shift (total 8 shifts). SCIRN stated the nursing staff should address each nursing problem on the care plan every shift so that nursing staff can provide appropriate care and address the nursing problem.

During a review of the facility's policy and Procedure (P&P) titled, "Multidisciplinary Plan of Care," dated 12/2022, the P&P indicated, "Planning for medical, nursing, and other clinical discipline(s) care, treatment, and service(s) is individualized to meet the patient's unique needs ... the plan is maintained and revised based on patient's response ...The care plan is initiated upon admission and the plan for presenting problems should be fully developed within 24 hours of admission. During the course of hospitalization, the plan should be updated as new issues arise or change in condition occur."

Based on interview and record review, the facility failed to ensure nursing admission assessments (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) were conducted within twenty-four (24) hours of admission and vital signs (measure basic function of the body including body temperature, blood pressure, heart rate or pulse and respiration) were checked and documented according to the appropriate level of care (from the most seriously ill to the less serious) for three of 30 sampled patients (Patients 9, 15, and 18), in accordance with the facility's policies and procedures regarding assessment, reassessment, and vital signs check.

This deficient practice had the potential for the inability to identify potential changes in patients' (Patients 9, 15, and 18) condition and can result in a delay of care, which may lead to worsening of patient condition and/or death.

Findings:

1. During a review of Patient 9's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/20/2024, the H&P indicated the following: Patient 9's chief complaint was congestive heart failure (CHF, a chronic condition in which the heart does not pump blood as well as it should) and morbid obesity (over 100 pounds of ideal weight). Likewise, Patient 9 reported eye redness and swelling.

During a review of Patient 9's "Admission Assessment (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected)," the Admission Assessment indicated, Patient 9's admission assessment was conducted on 1/21/2024 at 6:09 p.m., which was over 24 hours after admission orders were placed on 1/20/2024.

During a concurrent interview and record review, on 1/25/2024 at 11:45 a.m., with the Senior Clinical Informatics Registered Nurse (SCIRN) and the Corporate Director of Clinical Informatics (CDCI), the SCIRN and the CDCI stated the following: Patient 9 presented to the Emergency Department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) on 1/19/2024 at 10:48 p.m., for shortness of breath (difficulty breathing) and needlestick injury (skin is accidently punctured by a used needle).

In addition, Patient 9 had an order to be admitted to the Critical Care Unit (CCU, a unit that cares for serious, acute, and/or unstable cardiac [heart] conditions) on 1/20/2024 at 5:53 a.m. However, Patient 9 physically remained in the ED until he (Patient 9) was transferred to the CCU on 1/21/2024 at 6:25 p.m. Patient 9's admission assessment was performed on 1/21/2024 at 6:09 p.m., over 24-hours after the admission order was written. The SCIRN stated the admission assessment should have been completed within 24-hours of admission to help identify the patient's needs. The SCIRN confirmed there was a delay in completing the admission assessment for Patient 9.

During a review of the facility's policy and procedure (P&P) titled, "Assessment Reassessment #PC-160," dated 1/2024, the P&P indicated the following: "All admitted patients coming from the Emergency Department will have the Admission Assessment completed and documented within 24 hours of admission. The Admission assessment includes items such as: general patient history, screenings (travel ...) interpreter needs, communication and education needs, fall risk assessments ...abuse screenings ..."

2. During a review of Patient 15's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/27/2023, the H&P indicated Patient 15 was admitted for diabetic ketoacidosis (DKA, serious complication of diabetes [high blood sugar] that can be life-threatening). Patient 15's diagnoses included "uncontrolled diabetes and hypertension (high blood pressure) ... Plan: We will admit this patient (Patient 15) to intensive care unit (ICU, a unit that handles severe potentially life-threatening cases)."

During a review of Patient 15's "Physician's Order," dated 11/27/2023 at 9:06 a.m., the Physician's Order indicated "Admit to ICU."

During a review of Patient 15's "Admission Assessment (the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected)," the Admission Assessment indicated Patient 15's admission assessment was conducted on 11/28/2023 and 2:55 p.m., over 24 hours after admission orders were placed.

During a review of Patient 15's nursing "Flowsheet," record for vital signs (measure basic function of the body including body temperature, blood pressure, heart rate or pulse and respiration) documentation, dated 11/27/2023, the Flowsheet indicated the following:

At 6 a.m., Temperature (Temp) was 97.2 Fahrenheit (F, a unit of measurement), (normal 97.6 to 99.6 F), Blood pressure (BP) was 165/77 (high, normal 90/60 to 120/80), Heart Rate (HR) was 100 (normal is 60 to 100). Respiratory Rate (RR) was 18 (normal is 12 to 20), oxygen saturation (O2 sat) was 98 % (normal is 92 - 100 %).

At 8 a.m., no vital signs documented.

At 10 a.m., no vital signs documented.

At 11: 11 a.m., BP was 136/79 (high), HR was 99, RR was 16, and O2 sat was 98 %.

At 2 p.m., BP was 129/73 (high), HR was 91, HR was 86, RR was 12, and O2 sat was 99%.

At 4 p.m., no vital signs documented.

At 6 p.m., no vital signs documented.

At 8 p.m., Temp was 99.2, BP was 131/68 (high), HR was 83, RR was 14, and O2 sat was 96 %.

During a concurrent interview and record review, on 1/25/2024 at 4:23 p.m., with the Senior Clinical Informatics Registered Nurse (SIRN) and the Corporate Director of Clinical Informatics (CDCI), the SIRN and the CDCI stated the following: Patient 15 presented to the Emergency Department (ED) on 11/27/2023 at 5:27 a.m., for leg weakness and diabetic ketoacidosis. Patient 15 had an order to be admitted to the Intensive Care Unit (ICU) on 11/27/2023 at 9:06 a.m.

The SIRN stated when there was an order to admit a patient and a bed was not available, the nurse in the ED was expected to perform the same duties as if Patient 15 was physically in the ICU, including completing an initial admission assessment within 24-hours of admission and vital signs monitoring documentation, which should be done every 2 hours.

However, the ED nurse did not complete an initial admission assessment within 24 hours of admission as well as vital signs monitoring documentation when the patient (Patient 15) remained in the ED for more than 24 hours and had orders for ICU admission.

Both the SIRN and the CDCI confirmed that Patient 15 physically remained in the ED on 11/27/2023 and was not transferred to ICU due to lack of bed availability. There was a second admission order for Patient 15 to be admitted to the Neurology-Science unit (a specialized unit in the hospital that cares for patients with brain and spinal disorders) on 11/28/2023 at 9:12 a.m., since Patient 15 cannot be accommodated in the ICU. Patient 15 was then physically admitted to the Neurology- Science unit (responsible for the care of patients with immediate life-threatening problems of the brain, spinal cord [a column of nerve tissue that runs from the base of the skull down the center of the back], and nerves) on 11/28/2023 at 2:38 p.m. Patient 15's nursing admission assessment was only performed on 11/28/2023 at 2:55 p.m.

The SIRN and the CDCI verified the nursing admission assessment was performed over 24-hours after Patient 15's order for admission to the ICU was written on 11/27/2023. Likewise, the SIRN and the CDCI said that Patient 15's vital signs were not checked every two hours, on 11/27/2023, in accordance with the facility's policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Assessment Reassessment #PC-160," dated 1/2024, the P&P indicated the following: "All admitted patients coming from the Emergency Department will have the Admission Assessment completed and documented within 24 hours of admission. The Admission assessment includes items such as: general patient history, screenings (travel ...) interpreter needs, communication and education needs, fall (an unintentional event that results in the person coming to rest on the ground or another lower level) risk assessments ...abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient; abuse can be physical, verbal, emotional, or financial) screenings ...."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs," dated 8/2023, the P&P indicated vital signs will be done as follows: Critical Care Units - every two (2) hours ...Emergency Department (ED) - at triage (the process of quickly examining patients who are taken to the hospital in order to decide which ones are the most seriously ill and must be treated first) then as needed according to level of care (from the most seriously ill to the less serious).

3. During a review of Patient 18's "Emergency Face Sheet (face sheet, information including patient's basic information and demographic data), the face sheet indicated, Patient 18 went to the facility on 1/22/2024 at 4:11 a.m. due to right foot pain.

During a review of Patient 18's medical record titled "Hospitalist Consult Note (physician notes)," dated 1/23/2024, the physician notes indicated, Patient 18 had a mechanical fall (an unintentional event that results in the person coming to rest on the ground or another lower level) with blunt head trauma (injury to head due to head collides with a surface or object) and right minimally displaced fracture (broken bone, the ends of the bone came out of alignment) at 5th base metatarsal (the long bone on the outside of the foot that connects to the small toe). The physician notes also indicated Patient 18 had medical history of hypertension (high blood pressure).

During an interview on 1/23/2024 at 12:13 p.m. with Patient 18, Patient 18 stated she (Patient 18) was upset because her (Patient 18) blood pressure was high upon arrival to the facility's emergency room, but no one rechecked her (Patient 18) blood pressure or gave her (Patient 18) medication for the elevated blood pressure. Patient 18 stated she (Patient 18) had to tell the nurse to check her (Patient 18) blood pressure and after that she (Patient 18) eventually received blood pressure medication.

During a concurrent interview and record review on 1/24/2024 at 2:45p.m. with the Senior Clinical Informatics Registered Nurse (SCIRN), Patient 18's vital signs record (VS record) was reviewed. The VS record indicated the first set of vital signs were documented on 1/22/2024 at 4:10 a.m. with blood pressure of 205/86 (high, normal range 90/60 to 120/80) millimeters of Mercury (mmHg, a unit of measurement). The vital signs record indicated the next set of vital signs were documented on 1/22/2024 at 11:58 a.m. with blood pressure documented as 188/73 mmHg. SCIRN stated there was an eight-hour gap between the first set of vital signs and second set of vital signs.

SCIRN said vital signs should have been taken every 2 hours while patient (Patient 18) was in the emergency room. SCIRN stated that if the blood pressure was left untreated, there would be risk for stroke (brain attack, occurs when something blocks blood supply to part of the brain) and other complications.

During an interview on 1/25/2024 at 10:06 a.m. with the Director of Emergency Services (DIR 5), DIR 5 stated Patient 18's vital signs should have been checked every 2 hours.

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs #V-101," dated 09/2022, the P&P indicated, "Vital signs will be done minimally every one hour or more often as needed for emergent (immediate attention is required. Example: intervention for cardiac arrest [when the heart stops beating]) patients and every two hours for urgent (quick but not immediate action is required. Example: surgery that can be postponed for another day)/non-urgent (routine care for patients whose condition will not deteriorate over time and/or typically resolve on its own. Example: seasonal allergies, pregnancy tests, etc.) patients."