HospitalInspections.org

Based on document review and interview, it was determined for 1 of 10 (Pt#1) patients, the Hospital failed to ensure post operative assessments/vital signs were conducted per policy.

Findings include:

1. Pt #1's medical record was reviewed throughout the survey. Pt #1 is a 45-year-old who presented to hospital on 4/17/25 at 11:26 AM for a planned prophylactic bilateral mastectomy with DIEP (Deep Inferior Epigastric Perforator) flap reconstruction, scheduled for a staged surgery on 4/17/25 and 4/18/25. Pt #1 is positive for BRCA2+ (breast cancer gene 2) indicating high risk for breast cancer. Pt #1 has a history of morbid obesity, obstructive sleep apnea, and acid reflux, bariatric surgery, and a hysterectomy. Vital sign order dated 4/17/25 at 5:31 PM written by the Plastic Surgery Resident stated, " ...Vital signs every 4 hours for 24 hours, then twice daily." Pt #1's recordin included a "Vital Sign Flowsheet" dated 4/17/25 which indicated the following BP's:
-9:00 PM shows a low BP of 85/54 (normal BP range is 120/80) Pt #1's record lacks assessment, communication, or intervention related to low BP.
-10:00 PM - BP of 84/60.
-11:00 PM - BP of 90/59.
-12:00 AM - BP of 93/62.
The next recorded vital signs were taken at 5:55 AM (5 hours and 55 minutes after the last recorded vital signs) and indicated a BP of 92/61.
Pt #1's record lacks assessment, communication, or intervention related to the low BPs.

2. The policy titled "Nursing Documentation" (dated July 2024) was reviewed on 7/9/2025. The policy noted "...5. Ongoing Assessments a. Ongoing assessments may be completed by the RN (Registered Nurse) or delegated to the LPN (Licensed Practical Nurse)...b. Patients will be assessed at least once per shift (minimum of twice in 24 hours)...f. Reassessments occur in a problem-focused manner, as the patient's condition warrants, according to the plan of care, with a significant change in diagnosis...or response to previous care."

3. A review of an update titled "Nursing Practice Update" dated January 26, 2022 to February 4, 2022 was reviewed on 7/8/2025. It stated "...Post-op/post- procedure general status patients (vital signs) are now Q1Hx4 (every 1 hour for 4 hours), Q4Hx20 hrs (every 4 hours for 20 hours), then BID (twice daily)...If VS (vital signs) frequency changes, how will it be communicated? VS frequency will always be based on provider orders and will be clearly stated in Powerchart (Electronic Medical Record)..."

4. During an interview on 7/9/2025 at approximately 3:30 PM, the Patient Safety Coordinator (E #5) reviewed Pt#1's record and verbally agreed the record lacked the required assessments and vital signs per order and policy.