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RANDOLPH HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on review of hospital policy and Standards of Patient Care, medical record review, and staff interview, hospital nursing staff failed to reevaluate a patient's vital signs per hospital policy in 1 of 10 Emergency Department patients reviewed (Patient #3).
The findings include:
Review of hospital policy titled, " Vital Sign Documentation by Nursing Assistant (CNA) (Certified Nursing Assistant) " , Last Review Date: February 19, 2014, revealed, " ... II. Procedure: A. BP (Blood Pressure) Card will be provided to CNAs as a standard reference of measurement. ADULTS: SBP (Systolic Blood Pressure - the pressure exerted on the circulatory system when the heart contracts) < (less than) 100 > (greater than) 140. HR (Heart Rate) < 60 > 100 ... "
Review of Standards of Patient Care Emergency Department, Effective Date: July 22, 2014, revealed, " ... B. Emergency Severity Index (ESI): Triage Classification and Reassessment Guidelines ... 3. Level III (3) ... Reassessment occurs at a minimum, every 3 hours or more often as condition warrants ... Unstable vital signs are repeated every 30 minutes until stable, then hourly x (times) 1, and every 4 hours thereafter, or more frequently as condition warrants ... "
Closed medical record review revealed Patient #3 was a 33 year old male who presented to the hospital Emergency Department on 12/28/2015 at 1038, requesting inpatient detoxification treatment for alcohol abuse. Review revealed Patient #3 was triaged by Registered Nurse #1 on 12/28/2015 1047, who designated him an ESI Level III, and performed a vital sign assessment which read, " ... BP 169/102 (high); HR 132 (high)... " Review revealed no further vital sign assessments were performed during the duration of Patient #3' s admission to the Emergency Department. Patient #3 was discharged on 12/28/2015 1220.
Staff interview with Administrative Staff #1 revealed no other vital sign assessments were performed on Patient #3 after triage, and Emergency Department Standards of Patient Care were not followed.
NC00112685