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Based on record review and interview, the facility staff failed to complete vital signs - including a blood pressure reading on admission at a minimum, per facility policy, for 1 of 10 Patient's (#4) Emergency Department (ED) records in a total universe of 10 records reviewed.

Finding include:

A review of the facility's policy titled, "Care of the Patient Requiring Emergency Care" #11862654, Last Revised Date 07/28/2022 revealed, "A. When a patient presents to the Emergency Department: The emergency RN (Registered Nurse) collects comprehensive data pertinent to the health care consumer's health and/or situation: ...3. The initial assessment that is documented on all emergency patients will consist of the components of the mental status/neurological, cardiac, and respiratory assessments and any other systems pertinent to the patient's chief complaint and/or situation. Vital signs data pertinent to patient condition and age may include blood pressure, heart rate, respiratory rate, temperature, pulse oximetry, pain score and weight. B. Ongoing reassessments in the emergency department are done to determine the patient's response to interventions or to determine improvement or deterioration in patient condition. Reassessment data and intervals ware based on patient's condition. They may be as frequent as continuous monitoring or as infrequent as upon arrival and within 30 minutes prior to discharge/admission if needed. Higher acuity patients would receive more frequent reassessment."

During an interview on 06/19/3023 at 12:59 PM, Patient Care Supervisor B stated patients are triaged at an ESI (Emergency Severity Index- five level triage algorithm used for stratification of patients into 5 groups; 1 [most urgent] to 5 [least urgent]. Patient Care Supervisor B stated patients triaged at an ESI level of 3, 4, or 5 should have vital signs including a blood pressure completed on admission (except if they come in via ambulance) and every 4 hours.

A review of Patient #4's ED record revealed Patient #4 arrived at the ED on 06/18/2023 at 8:06 PM via personal car with a chief complaint of palpitations. Patient #4's triage assessment began at 8:06 PM and s/he was triaged at an ESI level 3. Patient #4 was discharged on 06/18/2022 at 11:32 PM. The only set of vital signs documented which included a blood pressure was completed at 11:30 PM. There was no blood pressure documented on admission to the ED.

During an interview on 06/19/2023 at 12:59 PM, findings in the medical records were confirmed with Patient Care Supervisor B. Supervisor B stated that when a patient comes in via a car, vital signs including a blood pressure should be completed upon admission and at a minimum at time of discharge from the ED. The nurses set a timer on the continual monitoring device however the nurse must validate the vital signs for them to flow into the permanent part of the medical record. The nurses are expected to validate the vitals.