HospitalInspections.org

Based on medical record review, document review, and staff interview, it was revealed the facility failed to follow their policy for obtaining vital signs in the Emergency Department (ED) for five (5) of five (5) patients presenting with behavioral health issues, Patients #4, 11, 12, 13 and 14. This failure has the potential to negatively impact all patients presenting to the ED for treatment.

Findings include:

A record review was conducted for patient #4. The patient presented to the ED on 11/12/22 at 4:33 p.m. with suicidal thoughts. The triage acuity level was documented as two (2). Vital signs were documented on 11/12/22 at 4:58 p.m. No additional documentation was noted of vital signs. The patient left the ED on 11/12/22 at 10:03 p.m.

A record review was conducted for patient #11. The patient presented to the ED on 11/10/22 at 5:57 p.m. with suicidal thoughts. The triage acuity level was documented as two (2). Vital signs were documented at 6:00 p.m., 7:15 p.m., 8:00 p.m. and 11/11/12 at 7:15 a.m. No additional documentation was noted of vital signs. The patient left the ED on 11/11/12 at 9:50 a.m.

A record review was conducted for patient #12. The patient presented to the ED on 11/12/22 at 9:36 p.m. with suicidal thoughts and depression. The triage acuity level was documented as two (2). Vital signs were documented on 11/12/22 at 9:44 p.m. and on 11/13/22 at 6:02 a.m. No additional documentation was noted of vital signs. The patient left the ED on 11/13/22 at 6:12 a.m.

A record review was conducted for patient #13. The patient presented to the ED on 11/12/22 at 7:24 p.m. with suicidal thoughts. The triage acuity level was documented as two (2). Vital signs were documented on 11/12/22 at 7:30 p.m. and on 11/13/22 at 2:44 p.m. No additional documentation was noted of vital signs. The patient left the ED on 11/13/12 at 3:00 p.m.

A record review was conducted for patient #14. The patient presented to the ED on 11/13/22 at 4:25 a.m. with suicidal thoughts. The triage acuity level was documented as two (2). Vital signs were documented on 11/13/22 at 4:29 a.m., 6:38 a.m., and 4:24 p.m., and on 11/14/22 at 7:15 a.m. No additional documentation was noted of vital signs. The patient left the ED on 11/14/12 at 9:10 a.m.

The policy titled, "CCMC [facility] Emergency Department Vital Signs and Re/Assessments Procedure," effective 10/25/22, was reviewed. The policy states in part: "Procedure: Vital Signs: ... Patients under care in the ED will have their Vital Signs repeated based on their emergency severity index (ESI) as assigned by the Triage RN ... ESI 2 [two] will have Vital Signs repeated every 30 [thirty] minutes or more often as condition of patient warrants. Exception: Psychiatric patients that are triaged as ESI 2 [two] but have no medical complaints and triage vitals are normal will have vital signs repeated every 2 [two] hours or as condition warrants. ESI 3 and 4: Vitals will be repeated every hour or as condition warrants ... All patients must have a full set of discharge of vital signs completed no later than 30 [thirty] minutes prior to discharge, transfer, or admission to the hospital ..."

An interview was conducted on 11/16/22 starting at 10:50 a.m. with the Clinical Nurse Manager (CNM) of the ED regarding obtaining vital signs from behavioral health patients in the ED. The CNM stated suicidal patients were assigned an acuity level of two (2) according to their policy, and placed in one of the four (4) behavioral health beds on Pod B, located behind a locked door and monitored by security cameras and security personnel. The CNM stated, "Vital signs should have been taken every two (2) hours while [Patients #4, 11, 12, 13, and 14] were in the ED, and thirty (30) minutes prior to discharge, but the policy was not followed."