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Based on record review and interview nursing staff failed to ensure that patient vital signs were recorded in patients' medical records and that laboratory specimens were collected from patients and sent to the hospital laboratory in accordance with the orders of physicians for 1 of 10 (patient #10) patients reviewed on survey. Findings are:

-Review of patient #10's medical record completed on 6/22/2017 indicates that nursing service staff did not document a body temperature reading for patient #10 when he presented at emergency department triage on 1/31/2017 at 1944.

-Review of the patient's medical record conducted on 6/22/2017 indicates that the Intensivist physician entered an electronic physicians order on 2/1/2017 at 0102 for two blood cultures and a stat sputum culture. A nursing note dated/timed 2/1/2017 at 0111 documented emergency department nursing staff giving transfer information regarding the patient to the intensive care unit nursing staff. The information that the blood cultures had not been drawn and the sputum culture had not been obtained was not communicated during the nurse to nurse "handoff". The medical record documented that these specimens were not received in the lab. Antibiotics were administered to the patient beginning at 0248 on 2/1/2017.

-The manager of patient safety verified the above information during a telephone interview completed on 6/23/2017 at 1430.

It is expected standard of practice that blood cultures and sputum cultures be obtained from patients prior to the administration of antibiotics.