HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that vital signs and pain assessments are performed for all patients in the emergency department in accordance with the facility's established timeframe.

Findings include:

Facility document titled, "Plan for Provision of Care: Assessment, Planning and Education-Appendix 1" (no date) stated, "... Department: Emergency Department; Assessment/Reassessment: ... Assessment of patient is a head to toe survey and a focused: physical assessment ...vital signs ... pain assessment ... The Triage RN and the ED Main treatment RN will reassess patients based on the category and individual patient needs/acuity, a minimum of every 120 minutes."

On 8/12/25 at 12:50 PM, upon review of Patient (P)1's medical record, in the presence of S3, the following was revealed:

P1 had a documented past medical history including diabetes, hyperlipidemia (high cholesterol), and hypertension (high blood pressure) who arrived at the ED on 07/10/25 at 1759 (5:59 PM) with complaint of "blurry vision." The arrival complaint was updated at 18:02 (6:02 PM) as "Blurred Vison, Headache." The patient's vital signs were as follows, Temperature: 97.8F (Fahrenheit); Heart Rate: 75; Respirations: 16; Blood Pressure: 149/74; oxygen saturation: 99% on room air. There was no pain assessment documented in the patient's triage note.

Upon further review, a pain assessment was completed by S11 at 1956 (7:56 PM) and documented that P1's pain was zero (no pain). The patient was discharged from the ED on 07/10/25 at 22:16 (10:16 PM). There was no other vital signs or pain assessment documented in the medical record.

The medical record lacked documentation that P1's vital signs and pain were assessed every 120 minutes between 19:56 (7:56 PM) and 22:16 (10:16 PM), in accordance with the facility's "Plan for Provision of Care" established timeframe.

During an interview with S5 on 8/12/25 at 1:40 PM, he/she confirmed vital signs should be documented every two hours.

S3 confirmed this finding at the time of the discovery.