HospitalInspections.org

Based on document review, the nursing director failed to assure appropriate standard of care was provided in the emergency department (ED) for 1 of 5 patients (patient #1).

Findings include:

1. Review of patient #1 medical record for visit #1 indicated the following:
(A) The patient presented to the ED on 12/6/10 with chief complaint that he/she had not slept in five (5) days and felt like dead weight. He/she arrived at 2:44 a.m. and was triaged at 2:46 a.m. Triage vitals were blood pressure (B/P) 134/93, pulse 96, respirations 18 and O2 saturation level 96%.
(B) Geodon 20 mg. IM was ordered. The injection was given at 7:49 a.m. on 12/6/10.
(C) Arrangements were made for transport/admission to facility #2. The patient was transferred at 9:55 a.m. Vital signs were B/P 89/51, pulse 72 and respirations 18.
(D) The medical record lacked documentation that the ED physician was notified of the low blood pressure by the nurse and/or that the patient was evaluated related to the low blood pressure prior to the transfer.
(E) Narrative nurses notes at 9:58 a.m. indicated that facility #2 was notified of the blood pressure by RN #1 and they (facility #2) requested that the patient be returned to facility until his/her B/P was stable.

2. Review of patient #1 medical record for visit #2 indicated the following:
(A) The patient was brought back to the ED and triaged at 11:03 a.m. on 12/6/10. His/her blood pressure was documented as 95/53 at the time of triage.
(B) An I.V. was started and I.V. fluids were administered.
(C) The patients blood pressure was documented as 116/75 at 1:00 p.m. and he/she was admitted to ICU for observation.