HospitalInspections.org

Based on review of medical records and staff interview, the facility failed to ensure all information necessary to monitor the patient's condition were documented.

Findings included:

Review of patient #1's medical record revealed physician orders dated 6/6/15 that stated in part, "Notify physician SBP [systolic blood pressure] < [less than] 90 or > [greater than] 160; DBP [diastolic blood pressure] < 60 or > 120; HR [heart rate] < 60 or > 110 ..."

Patient #1's vital signs on 6/13/15 at 5:04 am were BP of 84/64 and HR of 116; the SBP and HR were out of normal range.
His vital signs on 6/13/15 at 11:00 am were BP of 94/56 and HR of 112; the DBP and HR were out of normal range. There was no documentation the physician was notified of these vital signs.

Review of patient #10's medical record revealed physician orders dated 9/9/17 that stated in part, "Notify physician for SBP < 90 or > 160 ..." Patient #10 had a BP on 9/9/17 at 10:40 pm of 162/85; the SBP was out of normal range. No documentation of the physician notification was found.
The above was verified in an interview with staff #1 on the afternoon of 9/13/17. Staff #1 stated, "Nursing should be following doctor's orders."