HospitalInspections.org

Based on review of twelve Emergency Department (ED) medical records the ED nursing staff failed to ensure that the vital signs of four of the twelve patients were taken and recorded on the patient's medical record for periods of up to five and one half hours.

The findings include:
1. Patient #1, a 94 year old female with complaints of diarrhea and syncope on 8/16/10 lacked documentation of her temperature and pulse on admission to the ED at 12 04. The next vital signs documented for this patient were at 1445 and those vital signs lacked documentation of a blood pressure. Vital signs were taken every 15 minutes without written evidence of recorded blood pressure until 1718. All vital signs were documented every 15-30 minutes thereafter. There was no recorded temperature during her stay in the ED.

2. Patient #8, an 81 year old female with complaints of shortness of breath lacked documentation of her oxygen saturation readings for 5 hours and 45 minutes from 1811 to 2359 during her ED visit on 10/10/10. There was no written evidence of blood pressure recordings from 1811 to 2115 - a time frame of greater than 3 hours.

3. Patient # 16, an 81 year old female with complaints of diverticulitis lacked written evidence of vital signs during her 10/18/10 ED visit from 1215 to 1730 - a period of 5 hours and 15 minutes.

4. Patient #17, a 79 year old male, with complaints of right upper quadrant abdominal pain and bilateral lower abdominal pain lacked documentation of vital signs after triage at 1808 until 2133 - a period of 3 hours and 25 minutes during his 10/18/10 ED visit.