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Based on medical record review, staff interview, and policy review, the facility failed to follow their guidelines for the medical management of health problems for one of ten medical records reviewed (Patient #1).

Findings include:

Review of the policy titled, "Assessment," issued March 1992 and reviewed/revised 12/21, revealed a registered nurse would initiate an accurate and ongoing assessments of patients within the Emergency Center. Patients with an ESI (Emergency Severity Index) 3 classification would be reassessed every 30 minutes until the desired outcome was achieved. Reassessments would be performed for at least the following conditions: abnormal vital signs, altered mental status, PEWS (Pediatric Early Warning System) score greater than or equal to 3, and pain.

Review of the medical record for Patient #1 revealed arrival in the emergency department on 09/19/22 at 1:18 AM. Patient #1 had an ESI of 3. Patient #1's blood pressure was 168/98 at 1:26 AM. Patient #1 was discharged from the emergency department on 09/19/22 at 2:01 AM. The medical record lacked re-assessment of the blood pressure or any treatment for the blood pressure. Patient #1 was not on any blood pressure medications prior to arrival to the emergency department.

On 11/28/22 at 12:25 PM, Staff D verified in an interview that a second blood pressure was not obtained for Patient #1.

This deficiency represents non-compliance investigated under substantial allegation OH00136370.