HospitalInspections.org

Based on record review and interview the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for three of 15 patients (Patients #11, #3, #1) and failed to record height, weight, and/or vital signs on the initial assessment.

1) Patient #11 was admitted with Stage 2 Hypertension (high blood pressure). Nursing staff failed to take the patient's vital signs on admission.
2) Patient #3 had a medical history of high blood pressure and consumption of street drugs prior to admission. Nursing failed to obtain Patient #3's admission vital signs.
3) Patient #1's initial admission document reflected the patient weighed 148 pounds. Forty-five minutes later, the admitting physician noted the patient to weigh 180 pounds. Nursing admission staff failed to obtain an accurate weight for Patient #1.

Findings included:

1) Patient #11's Integrated Intake and Psychosocial Assessment dated 07/30/16 at 0500 reflected the patient's medical condition included high blood pressure.

The History and Physical Exam document dated 07/30/16 at 0700 reflected the patient's blood pressure to be 166/104 mmHg.

Patient #11's Initial Nursing Assessment was completed on 07/30/16 at 1000. There was no evidence of documented vital signs.

The American Heart Association considered a blood pressure higher than 160/100 to be Stage 2 High Blood Pressure (Hypertension) and noted that high blood pressure can lead to stroke, heart attack, kidney failure, and even heart failure(http://www.heart.org).


2) Patient #3's Initial Nursing Assessment dated 08/01/16 at 1110 AM. It reflected the patient's medical history of high blood pressure. There were no vital signs recorded.

Patient #3's Physician Psychiatric Evaluation dated 08/01/16 at 1457 reflected the patient's suicide attempt prior to admission. The patient had relapsed on multiple substances and took street-acquired Suboxone medication (prescription medicine indicated for treatment of opioid dependence).

Common side effects of Suboxone included drug withdrawal symptoms, light-headedness, dizziness, and fainting (http://www.suboxone.com/content/pdfs/SuboxoneISI.pdf).

3) Patient #1's Integrated Psychosocial Assessment dated 10/30/15 at 1800 reflected the patient's high suicide risk. Patient #3's weight was recorded at 148 pounds.

Patient #1's Physician Preadmission Examination Orders dated 10/30/15 at 1845 noted admission diagnoses of Major Depressive Disorder and Anxiety Disorder. The physician recorded the patient's weight as 180 pounds.

Patient #1's Initial Nursing Assessment was completed on 10/30/15 at 1930. The space to document the patient's weight was left blank.

Hospital Personnel #10 acknowledged the above findings during an interview on 08/05/16 at 0950.