HospitalInspections.org

Based on document review and interview, nursing services failed to perform vital signs per policy for 5 of 10 medical records reviewed. (P#3, P#5, P#6, P#7, and P#10).

Findings include:

1. Facility policy titled, Assessment and Documentation Of The Emergency Room Patient, policy number ED8, last revised 02/06/2023, indicated ESI ( Emergency Severity Index) Level 2: vital signs will be documented upon admission then every 1 hour thereafter if stable. A full set of vital signs will be documented if a change in condition is noted.


2. Medical record (MR) review completed on 05/20/2024 indicated the following:
a. P3 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 2053 hours on 04/15/2024 through 0013 hours on 04/16/2024.

b. P5 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 0053 hours on 4/18/24 through 0354 hours on 4/18/2024.

c. P6 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 1838 hours on 04/18/2024 through 0051 on 04/19/2023.

d. P7 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 1225 hours on 4/19/2024 through 1916 hours on 04/19/2023.

e. P10 MR indicated ESI level 2, record lacked documentation of vital signs completed every 1 hour per policy from 2058 hours on 04/20/2024 through 0359 hours on 04/21/2024.


3. In interview on 05/20/2024 at approximately 1420 hours, A4 (Manager of of Risk Management and Privacy), confirmed medical records lacked documentation of vital signs every 1 hour per policy for ESI level 2 patients in the Emergency Room.