HospitalInspections.org

Based on policy review and medical record review, the facility does not ensure Emergency Department (ED) patients are reassessed following triage and prior to discharge in accordance with facility procedures in 4 of 31 patients reviewed (Patient #1, 26, 28 and 31).

Findings Include:

Review on 04/02/19 of facility policy "Clinical Practice: E.C & W.I.C.C- Care Guidelines and Order Sets" last revised 02/01/19 revealed for patients with acuity levels of 1, 2, 3 vital signs are taken initially and then every 2 hours or more frequently if unstable or change in status. Once in ED 4 hours or longer and stable, vital signs are to be recorded every 4 hours.

Interview on 04/02/19 at 02:30PM with Staff (H), RN, Quality verified that ED staff follow the "Clinical Practice Procedures: Care Guidelines and Order Sets" including obtaining vital signs within an hour of discharge and that this information is relayed to staff during orientation.

Review on 04/02/19 of ED medical records revealed Patient #1, 26, 28 and 31 presented to the ED on 02/10/19 and were assigned an emergency severity index (acuity level) 3. For Patient #1, vital signs were obtained at 06:28AM and at 09:48AM an emergency medical situation occurred with no documentation of a recent set of vital signs. For Patient #26, vital signs were obtained at 03:09PM and not repeated until 06:10PM. For Patient #28 vital signs were obtained at 12:00PM and again at 02:01PM. At 06:22PM Patient #28 was discharged to home with no further documentation of vital sign monitoring. For Patient #31, vital signs were obtained at 07:56AM and again at 10:15AM. At 01:04PM Patient #31 was discharged to home with no further documentation of vital sign monitoring.

Interview on 04/02/19 at 11:15AM with Staff (J), ED RN confirmed the above findings.