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Based on interview and record review, the hospital failed to ensure the nursing staff assessed the vital signs every two hours for three of four sampled patients (Patients 1, 2 and 3) as per the hospital's P&P. This failure created the risk for substandard health outcomes to these patients.

Findings:

Review of the hospital's P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed the purpose is to establish the guidelines for performing the ED assessments and reassessments for the initial and ongoing care and/or observation of the patients in treatment areas or those who are waiting for the placement in the treatment area. The primary nurse responsibilities for the assessments and reassessments include to complete the more in depth assessments when the patients are in the treatment areas; obtain the initial complete vital signs including blood pressure, heart rate, temperature, respiratory rate, and pain score; and assure the subsequent vital signs and assessments are completed at least every two hours for ESI levels 2 and 3 patients and/or more frequently based on the patients' conditions and/or changes.

1. On 10/4/24, review of Patient 3's medical record was initiated. Patient 3's medical record showed the patient came to the ED on 10/2/24.

Review of Patient 3's General Triage Assessment and Chief Complaint/Mechanism of Injury showed the patient presented to the hospital and was assessed with a tracking Acuity (ESI) level of 2.

Review of Patient 3's documented vital signs showed the following:

* On 10/02/24 at 1610 hours, Patient 3's vital signs were: T-36.8 degrees C, HR- 69 bpm, RR-18 br/min, BP-120/87 mmHg.
* On 10/02/24 at 1810 hours, no vitals were taken or documented for Patient 3 as per the hospital's P&P.
* On 10/02/24 at 2010 hours, no vitals were taken or documented for Patient 3 as per the hospital's P&P.
* On 10/02/24 at 2112 hours Patient 3's vital signs were: T-37 degrees C, HR-68 bpm, RR-18 br/min, BP- 150/89 mmHg.
* On 10/02/24 at 2200 hours Patient 3's vital signs were: T-37 degrees C, HR- 88 bpm, RR-17 br/min, BP- 164/95 mmHg.
* On 10/03/24 at 0000 hours Patient 3's vital signs were: T- 37 degrees C, HR- 89 bpm, RR-16 br/min, BP 165/78 mmHg.
* On 10/03/24 at 0200 hours Patient 3's vital signs were: T-36.6 degrees C, HR- 79 bpm, RR-18 br/min, BP-136/108 mmHg.

On 10/04/24 at 1255 hours, an interview and concurrent medical record was conducted with the Director of Quality. The Director of Quality verified Patient 3 was admitted to the ED on 10/02/24 with an ESI level of 2. The Director of Quality reviewed Patient 3's vital signs. The Director of Quality verified no vital signs were documented for Patient 3 on 10/2/24 at 1810 or 2010 hours. The Director of Quality reviewed the hospital's ED P&P and verified the expectation was to follow the hospital's P&P. The Director of Quality stated the purpose of assessing a patient's vital sign was to assess the patient's status, cardiovascular stability and mentation of the patients. The Director of Quality also verified once vital signs were again assessed and documented, Patient 3 had the documented elevated blood pressure. The Director of Quality stated by not taking the vital signs for five hours, Patient 3's elevated blood pressures could have occurred during those five hours and could have been a sign of additional health problems and cardiovascular events leading to a poor outcome.

On 10/04/24 at 1525 hours, an interview was conducted with Senior Director of Critical Care and ED. The Senior Director of Critical Care Services and ED verified she was also the Director of the ED. The Senior Director of Critical Care Director and ED reviewed the hospital's P&P for ED, Triage, Assessment and Reassessment Standards. The Senior Director of Critical Care Services and ED stated the policy was for the ED nursing staff. The Director of Critical Care Services and ED stated the expectation was for the nursing staff to follow this hospital's P&P in both areas, triage and treatment areas. The Senior Director of Critical Care Services and ED verified Patient 3 was admitted on 10/02/24 at 1608 hours. The Senior Director of Critical Care Services and ED verified Patient 3 was triaged with the acuity level of 2. The Senior Director of Critical Care Services and ED stated per the hospital's policy, patients with an ESI level of 3 or 2 were to have their vital signs assessed every two hours. The Senior Director of Critical Care Services and ED reviewed Patient 3's medical record and verified Patient 3's vital signs were taken on 10/02/24 at 1610 and then 2112 hours. The Senior Director of Critical Care Services and ED stated per the hospital's policy, the expectation was to take vital signs every two hours for Patient 3. Based on the initial assessment, Patient 3 should have assessed for vital sign assessment at approximately 1800 and 2000. The Senior Director of Critical Care Services and ED stated it was a missed opportunity for the nursing staff to follow the hospital's P&P.

The Senior Director of Critical Care Services and ED and Director of Quality were both informed and acknowledged the findings.


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2. On 10/4/24, Patient 1's closed medical record was reviewed. Patient 1's closed medical record showed the patient was admitted to the hospital on 9/11/24, with a chief complaint of psychiatric problem. Patient 1 was triaged to have an acuity level of 3.

Review of the Interactive View/I &O flowsheet dated 9/12/24 showed under the section of Vital Signs, the RN had assessed the patient's vital signs every two hours as follows:

- At 0800 hours, the patient's temperature was 36.4 degrees C. The patient's pulse rate was 74 bpm. The patient's respiratory rate was 16 br/min. And the patient's BP was 110/74 mmHg.

- At 1000 hours, the patient's temperature was 36.9 degrees C. The patient's pulse rate was 94 bpm. The patient's respiratory rate was 18 br/min. And the patient's BP was 140/84 mmHg.

However, review of vital signs flowsheet failed to show documented evidence the patient's vital signs were taken at 1200 hours or after two hours as per the hospital's P&P.

On 10/4/24 at 1124 hours, an interview and concurrent medical record review was conducted with the Senior Director of Clinical Care and ED. The Senior Director of Clinical Care and ED was asked how often the vital signs were taken. The Senior Director of Clinical Care and ED stated every two hours. The Senior Director of Clinical Care and ED was also asked when the last set of vital signs was taken. The Senior Director of Clinical Care and ED stated the last set of vital signs was taken at 1000 hours. The Senior Director of Clinical Care and ED was further asked if the patient's vital signs were taken at 1200 hours. The Senior Director of Clinical Care and ED stated there was, but it was not documented on the chart. The Senior Director of Clinical Care and ED further stated the staff took the vital signs, but it was not logged. The Senior Director of Clinical Care and ED was informed and acknowledged the findings.

3. Review of Patient 2's medical record was initiated on 10/4/24. The patient went to the hospital on 9/30/24 at 2249 hours. The patient had a chief complaint of overdose.

Review of the Tier 2 Triage dated 9/30/24 at 2256 hours, showed the patient was triaged with the acuity level of 2.

Review of the Interactive View/I &O flowsheet dated 10/3/24, showed under the section for Vital Signs, the RN had assessed the patient's vital signs every two hours as follows:

- At 1400 hours, the patient's BP was 138/96 mmHg. The patient's pulse rate was 74 bpm. The patient's respiratory rate was 18 br/min. And the patient's temperature was 36.6 degrees C.

- At 1600 hours, the patient's BP was 139/100 mmHg. The patient's pulse rate was 70 bpm. The patient's respiratory rate was 18 br/min. And the patient's temperature was 37.0 degrees C.

- At 1800 hours, the patient's BP was 151/106 mmHg. The patient's pulse rate was 88 bpm. The patient's respiratory rate was 18 br/min. And the patient's temperature was 36.5 degrees C.

Further review of the Interactive View/I &O flowsheet showed the sections of BP, pulse rate, and respiratory rate was left blank on 10/3/24 at 2000 hours.

On 10/4/24 at 1030 hours, an interview was conducted with MHA 1. MHA 1 was asked about the frequency of vital signs monitoring. MHA 1 stated every two hours.

On 10/4/24 at 1100 hours, an interview was conducted with RN 3. RN 3 was asked about the frequency of the vital signs monitoring. RN 3 stated every two hours.

On 10/4/24 at 1354 hours, an interview and concurrent medical record review was conducted with the Senior Director of Clinical Care and ED. The Senior Director of Clinical Care and ED was asked about the frequency of the vital signs for a patient with the ESI level 2. The Senior Director of Clinical Care and ED stated every two hours. The Senior Director of Clinical Care and ED was also asked if they needed to recheck the patient vital signs if the BP was elevated. The Senior Director of Clinical Care and ED stated it did not look like there was. The Senior Director of Clinical Care and ED was informed and acknowledged the findings.

On 10/4/24 at 1526 hours, a follow-up interview and concurrent document review was conducted with the Senior Director of Clinical Care and ED, Director of Quality, and Chief Operating Officer. They were asked if the hospital's P&P related to ED Triage, Assessment and Reassessment Standards was applicable for the patient. The Senior Director of Clinical Care and ED stated yes. They were informed and acknowledged the findings.