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Based on interview and record review, the facility failed to ensure adequate RN supervision and assessment of patient needs for 1 of 10 Emergency Department patients ( Patient ID # 1).

Emergency Department (ED) nursing staff failed to appropriately monitor and assess Patient ID #1's blood pressure based on the severity of his condition.

Findings include:

Intake # TX 00155754

Record review of Patient ID #1 ' s clinical record revealed he was 68 years old and admitted to the facility ED via ambulance at on 12-14-2011 at 2:27 p.m. He was triaged at 2:28 p.m with a chief complaint documented as "Headache, Abdominal Pain, and ETOH Abuse."

Review of the ED physician assessment dated 12-14-11 revealed Patient ID # 1 was alert and oriented and his chief complaint was " fall. " In addition, it was documented the patient was complaining of nausea and vomiting. The " Clinical Impression " documented by the ED physician read: " 1. Hypertensive Emergency 2. Fall. 3. Intraventricular Hemorrhage. "

A CT Scan of the head was done on 12-14-11 at 4:30 p.m. that showed evidence of a stroke: " hemorrhage within the right basal ganglia with extension into the ventricular system ... " An additional CT of the head was done on 12-14-11 at 10: 42 p.m. that showed " small amount subarachnoid hemorrhage...stable CT as compared to earlier CT... "

Further review of Patient ID # 1 ' s clinical record for 12-14-11 revealed the following:

Traiage assessment at 2: 28 p.m.; blood pressure was 177/117.

An additional blood pressure measurement was not obtained until 2 hours and 33 minutes later at 5:01 p.m. At this time, Patient ID # 1 ' s blood pressure was documented as 196/117; he was medicated with Enalipril 1.25 milligrams (mg) Intravenous (IV) Push.

5:11 p.m. blood pressure documented as 179/106

6 :00 p.m: blood pressure documented as 170/107

7:17 p.m.:blood pressure was 206/143 . Patient ID # 1 was medicated with Labetalol 20 mg IV push; shortly thereafter, Patient ID # 1 ' s blood pressure was 157/101.

9:15 p.m: blood pressure was 187/ 114 ; Patient ID # 1 was medicated with Hydralizine 20 mg IV Push. Blood pressure was not re-assessed until 1 hour and 15 minutes later at 10:30 p.m., when it was 116/72.

Interview on 02-22-12 at 1:45 p.m. with the ED Director (ID # 59) she stated that Patient ID # 1 ' s admission blood pressure was " very high and it should have been monitored more frequently while he was in the ED."

Review of policy titled " Assessment Reassessment (Emergency Services), " review date 02-20-2011, revealed " " ...3.3 the frequency of reassessment is based on the patient ' s acuity, condition, history and complaint, or as directed by the physician; minimally every four (4) hours.