HospitalInspections.org

Based on hospital policy and procedure review and staff interview, the emergency department (ED) nursing staff failed to assess/monitor vital signs every 2 hours (#21, #24, #30) and provide pain intervention (#21) according to hospital policy for 3 of 10 sampled patients.

The findings include:

Review of current hospital policy "Nursing documentation of patient care in the Emergency Department," revised May 11, 2012, revealed "POLICY....3. Patients given an ESI triage level of 1, 2, or 3 may require vital signs more frequently due to acuity, the patient ' s clinical condition, and medical treatments that warrant more frequent vital signs. The standard minimum of documentation will be vital signs every 2 hours."

Review of current hospital policy "Triage and Classification System" revised March 13, 2012 revealed "B. Triage acuity levels will be based on the Emergency Severity Index (ESI) categories 1-5 with 1 being the sickest patient ...d) Severe pain is defined as 7 out of 10 on the pain scale...C. Vital Signs: the measurement of heart rate, respiratory rate and oxygen saturation (SpO2%)."

Review of current hospital policy "Pain Management Policy" revised March 2009 revealed "I. Assessment/Management...C. The assessment will be performed at the time of patient 's self-report of pain...This assessment will occur - At any time the patient reports or exhibits signs and symptoms of pain - Within one hour after an intervention of pain...Intervene by utilizing the most effective method possible to decrease the pain...Document your assessment, your intervention and the patient's response to your interventions..."

1. Closed medical record review of Patient #21 revealed a 23 year old female presented to the ED on 09/06/2014 at 1941 with a chief complaint of pain on left side of the body. Record review revealed the patient was triaged at 2003 and assigned an ESI Level 3. Record review revealed initial vital signs at 2003 were blood pressure (BP) 139/88, P 86, RR 16, SpO2% 100 room air (RA), temperature (T) 99.2 degrees Fahrenheit (F), and pain level 8 (on a scale of 1 to 10, with 10 being the most severe). Record review revealed no documentation of vital signs done every 2 hours or provision of pain intervention to the patient. Record review revealed documentation at 2358 (3 hours 55 minutes after initial assessment) the staff called into the lobby for the patient "no response." Record review revealed documentation at 0028 (30 minutes after first call to lobby) a second call was made in the lobby for the patient with another "no response." Record review revealed documentation at 0133 (1 hour 5 minutes after second call) a third call to the lobby for the patient with another "no response." Record review revealed documentation "patient left prior to medical screening exam" at 0134 recognized time when patient left. Record review revealed no documentation of reassessment of vital signs or pain.

Interview with the ED Assistant Director on 11/13/2014 at 1520 revealed Patient #21 was triaged as an ESI Level 3 requiring vital signs to be reassessed every 2 hours according to hospital policy. Interview revealed there was no available documentation of a reassessment of the patient after initial triage. Interview revealed with pain rated at 8, required the nursing staff to address and document any intervention. Interview revealed no available documentation of the patient's pain was reassess or any intervention was provided.

2. Closed medical record review of Patient #24 revealed a 57 year old male presented to the ED on 09/14/2014 at 1703 with a chief complaint suicidal ideation. Record review revealed the patient was triaged at 1730, assigned an ESI Level 2 with initial vital signs BP 130/85, P 83, RR 16, SpO2% 95 RA, T 98.7 degrees F, and no pain. Record review revealed documentation the patient had a plan for suicide "hanging" himself. Record review revealed no further documentation of vital signs done every 2 hours. Record review revealed documentation at 2101 (3 hours 31 minutes after initial assessment) the staff called into to the lobby for the patient "no response." Record review revealed documentation at 2115 (14 minutes after first call to lobby) a second call was made in the lobby for the patient with another "no response." Record review revealed documentation at 2234 (19 minutes after second call) a third call to the lobby for the patient with another "no response." Record review revealed documentation "patient left prior to medical screening exam" at 2235.

Interview with the ED Assistant Director on 11/13/2014 at 1520 revealed Patient #24 was triaged as an ESI Level 2 requiring vital signs to be reassessed every 2 hours according to hospital policy. Interview revealed there was no available documentation of a reassessment of the patient after initial triage. Interview revealed the patient having thoughts of hanging himself that the nursing staff should "make room for this patient" by moving other patients out in the hallway. Interview revealed the staff should have provided some types of monitoring so "he won't hurt himself." Interview revealed there was no available documentation of the patient being placed in a room or monitored.

3. Closed medical record review of Patient #30 revealed a 63 year old female presented to the ED on 07/19/2014 at 1449 with a chief complaint of double and triple vision with questionable signs/symptoms of a stroke. Record review revealed the patient was triaged at 1454, assigned an ESI Level 3 with initial vital signs at 1454 were BP 143/81, P 89, RR 16, SpO2% 96 RA, T 96 degrees F. Record review revealed the patient's vital signs were reassessed at 1855 as BP 147/85, P 81, RR 18, SpO2% 97 RA, T 98.9 (4 hours 1 minutes after initial assessment). Record review revealed no further documentation of vital signs being assessed every 2 hours. Record review revealed at 1930 the patient signed out as against medical advice

Interview with the ED Assistant Director on 11/13/2014 at 1520 revealed Patient #30 was triaged as an ESI Level 3 requiring vital signs to be reassessed every 2 hours according to hospital policy. Interview revealed there was no available documentation of a reassessment of the patient's vital signs done every 2 hours.

NC 00100398