HospitalInspections.org

Based on facility policy review, medical record review, and administrative staff interview, nursing staff failed to supervise the care of patients by failing to assess vital signs per facility policy in 6 of 10 emergency department patients (Patient #1, #3, #4, #5, #6, and #9).

The findings include:

Review of facility policy titled, "Vital Signs in the Emergency Department", revision date 3/2017, revealed, "...Vital Signs Frequency: ESI (Emergency Severity Index) Level 1 & (and) 2: Minimum of every hour or as clinically indicated ESI Level 3: Minimum of every 2 hours or as clinically indicated ESI Levels 4 and 5: Minimum of every 3 hours and as needed... Should be repeated within 1 hour of disposition... Vital signs include BP (Blood Pressure), pulse, respiratory rate, oxygen saturation, temperature and pain..."

1. Medical record review revealed Patient #1 was a 22 year old female that presented to the emergency department on 03/15/2017 at 1621, with a complaint of, "MVC (Motor Vehicle Collision), left shoulder and right ankle pain." Patient #1 was assigned an ESI Level 2. Vital signs obtained at 1624 were as follows: BP 154/83, P (Pulse) 94, R (Respirations) 24, T (Temperature) 98.7, SpO2 (Oxygen Saturation) 99 % (Percent) RA (Room Air), and Pain (not assessed). Vital signs obtained at 1719 were as follows: BP 139/79, P 93, R 16, T (not assessed), SpO2 99 % RA, and Pain (not assessed). Vital signs obtained at 1851 (1 hour and 32 minutes later) were as follows: BP 120/70, P 92, R 20, T (not assessed), SpO2 99 % RA, and Pain 7 of 10 (pain rating scale, 0 equals no pain, 10 equals the worst pain). Vital signs obtained at 1915 were as follows: BP 107/60, P 89, R 20, T (not assessed), SpO2 99 % RA, and Pain 7 of 10. Patient #1 was discharged at 2120 (2 hours and 5 minutes later). Documentation revealed no vital sign assessment within one hour of discharge.

Administrative staff interview conducted with Director of Patient Care (DPC) #1 revealed lapses in vital sign assessment per facility policy in the emergency department are a known problem, and the policy is currently under review, however no policy changes or staff education has occurred.

2. Medical record review revealed Patient #3 was a 63 year old male that presented to the emergency department on 03/18/2017 at 1659, with a complaint of, "MVC last night, eyes hurt, neck sore." Patient #3 was assigned an ESI Level 4. Vital signs obtained at 1701 were as follows: BP 119/74, P 71, R 16, T 97.9, SpO2 97 % RA, and Pain 3 of 10. Patient #3 was discharged at 1939 (2 hours and 38 minutes later). Documentation revealed no vital sign assessment within one hour of discharge.

Administrative staff interview conducted with Director of Patient Care (DPC) #1 revealed lapses in vital sign assessment per facility policy in the emergency department are a known problem, and the policy is currently under review, however no policy changes or staff education has occurred.

3. Medical record review revealed Patient #4 was a 31 year old male that presented to the emergency department on 03/19/2017 at 0102, with a complaint of, "struck by a pickup truck." Patient #4 was assigned an ESI Level 2. Vital signs obtained at 0107 were as follows: BP 103/59, P 86, R 18, T 98.7, SpO2 99 % RA, and Pain 10 of 10. Vital signs obtained at 0324 (2 hours and 17 minutes later) were as follows: BP 123/66, P 90, R 16, T (not assessed), SpO2 99 % RA, and Pain 10 of 10. Patient #4 was discharged at 0714 (3 hours and 50 minutes later). Documentation revealed no vital sign assessment within one hour of discharge.

Administrative staff interview conducted with Director of Patient Care (DPC) #1 revealed lapses in vital sign assessment per facility policy in the emergency department are a known problem, and the policy is currently under review, however no policy changes or staff education has occurred.

4. Medical record review revealed Patient #5 was a 58 year old female that presented to the emergency department on 03/31/2017 at 2000, with a complaint of, "MVC, low back pain." Patient #5 was assigned an ESI Level 4. Vital signs obtained at 2035 were as follows: BP 151/81, P 60, R 20, T 97.8, SpO2 96 % RA, and Pain 10 of 10. Vital signs obtained at 2306 were as follows: BP 135/70, P 90, R 18, T (not assessed), SpO2 100 % RA, and Pain 7 of 10. Patient #5 was discharged on 04/01/2017 at 0247 (3 hours and 31 minutes later). Documentation revealed no vital sign assessment within one hour of discharge.

Administrative staff interview conducted with Director of Patient Care (DPC) #1 revealed lapses in vital sign assessment per facility policy in the emergency department are a known problem, and the policy is currently under review, however no policy changes or staff education has occurred.

5. Medical record review revealed Patient #6 was a 28 year old male that presented to the emergency department on 03/19/2017 at 0732, with a complaint of, "MVC this AM (morning), neck stiff, low back pain." Patient #6 was assigned an ESI Level 3. Vital signs obtained at 0735 were as follows: BP 177/93, P 69, R 16, T 98.4, SpO2 98 % RA, and Pain 5 of 10. Vital signs obtained at 0823 were as follows: BP 157/94, P (not assessed), R (not assessed), T (not assessed), SpO2 (not assessed), and Pain (not assessed). Vital signs obtained at 0912 were as follows: BP 161/90, P (not assessed), R (not assessed), T (not assessed), SpO2 (not assessed), and Pain 2 of 10. Vital signs obtained at 1005 were as follows: BP 161/91, P 88, R 16, T (not assessed), SpO2 (not assessed), and Pain 2 of 10.

Administrative staff interview conducted with Director of Patient Care (DPC) #1 revealed lapses in vital sign assessment per facility policy in the emergency department are a known problem, and the policy is currently under review, however no policy changes or staff education has occurred.

6. Medical record review revealed Patient #9 was a 78 year old female that presented to the emergency department on 05/09/2017 at 1139, with a complaint of, "2 months history of hip pain without injury or known cause." Patient #9 was assigned an ESI Level of 3. Vital signs obtained at 1141 were as follows: BP 139/72, P 99, R 16, T 97.6, SpO2 97 % RA, and Pain 7 of 10. Vital signs obtained at 1311 were as follows: BP (not assessed), P (not assessed), R (not assessed), T (not assessed), SpO2 (not assessed), and Pain 5 of 10. Vital signs obtained at 1423 were as follows: BP 129/71, P 64, R 16, T (not assessed), SpO2 98 % RA, and Pain 0 of 10.

Administrative staff interview conducted with Director of Patient Care (DPC) #1 revealed lapses in vital sign assessment per facility policy in the emergency department are a known problem, and the policy is currently under review, however no policy changes or staff education has occurred.

NC00127417