HospitalInspections.org

Based on document review, record review and interview the nursing staff in the Emergency Department did not document patient re-assessment in accordance with the facility's standards of nursing practice for 2 of 22 pediatric patients (Patient #1 and 16).

Findings Include:

Review on 09/12/19 of the facility's Pediatric Emergency Standard of Care document last updated 05/2019 revealed vital signs are to be completed minimally every two hours and progress notes are required for documentation of response to therapy/medications.

Review on 09/12/19 of the medical record for Patient #1 dated 07/15/19 revealed vital signs were obtained at 03:36 PM following the patient's arrival and Motrin was administered at 04:14 PM. A nursing progress note is not documented following the medication administration and repeat vital signs were not obtained until 06:38 PM, three hours after the initial set and just prior to the patient's discharge.

Review on 09/12/19 of the medical record for Patient #16 dated 09/10/19 revealed vital signs were obtained at 04:35 PM and not repeated until three hours later at 07:38 PM.

Interview with Staff (D), ED safety nurse on 09/12/19 at 01:30 PM verified the above findings.