HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff followed physician orders related to assessing patients' vitals per unit policy every six hours for 4 of 10 medical records (MR) reviewed, failed to ensure nursing staff followed physician orders related to physician notification of vitals out of parameters for 4 of 10 medical records reviewed and failed to ensure nursing staff reassessed patient vitals that were out of physician ordered parameters for 4 of 10 patients (patients #1, 2, 3 and 5).

Findings include:

1. Facility policy # NUR166, titled "ROUTINE VITAL SIGNS", last reviewed/revised 12/2018 indicated the following: "PURPOSE: Vital signs are taken to individuate the physiologic body function of a patient by establishing a baseline and observing for any changes...To monitor patient's vital signs, establish a baseline and observe for any changes...POLICY: The following guidelines will be utilized in taking vital signs: ...B. All In-Patients & Post-Op [operative] Patients: 1. Temperature, pulse, respiration, blood pressure and pulse oximetry are taken at least once every 6 hours shift, or as per physician order. Vital signs are to be taken more frequently as patient condition warrants...Alterations of a patient's vital signs is often the first indicator of a change in patient's condition...DOCUMENTATION: ...2. Chart all vital signs on the flowsheet in the medical record..."

2. Facility policy titled "NOTIFICATION OF PHYSICIAN WITH CHANGE IN PATIENT CONDITION-GUIDELINES FOR CALLING PHYSICIAN..." last reviewed/revised 12/2018 indicated the following: "...PURPOSE: ...Communicating with the physician regarding changes in patient condition is necessary to provide continuing patient care and provide the appropriate treatment to patients. POLICY: 1. The physician will be notified of changes in patient condition...when they occur...2. The admitting physician is the attending physician and will be notified of any changes in patient's condition unless a written order on the medical record states otherwise...PROCEDURE: ...2. Nurse will call physician with pertinent information/condition change. 3. Document physician notification..."

Review of patient #1's medical record indicated the following:

(A) The patient was admitted on 6/11/19 at 2247 hours and transferred to the Intensive Care Unit on 6/17/19 at 1750 hours.

(B) The patient had the following physician orders:

"...Vital Signs...Per unit policy...Start Date/Time 6/6/2019 17:32 [hours]...Stop Date/Time 6/20/2019 18:11 [hours]..."

"...Notify Provider Vital Signs...Start Date/Time: 6/6/2019 [at] 17:32 [hours]...and End-state Date/Time: 6/20/2019 [at] 18:11 [hours]..., Notify Psychiatrist and Adult Medicine Physician, T [temperature] greater than 99.5 F [Fahrenheit]..."

"...Notify Provider Vital Signs...Start Date/Time: 6/6/2019 [at] 17:32 [hours]...and End-state Date/Time: 6/20/2019 [at] 18:11 [hours]...,Notify Psychiatrist and Adult Medicine Physician, HR [heart rate] greater than 120 bpm [beats per minute] or, HR less than 50 bpm..."

"...Notify Provider Vital Signs...Start Date/Time: 6/6/2019 [at] 17:32 [hours]...and End-state Date/Time: 6/20/2019 [at] 18:11 [hours]..., Notify Psychiatrist and Adult Medicine Physician, DBP [diastolic blood pressure] greater than 100 mm Hg [millimeters of mercury]..."

On 6/8/19 at 1000 hours, Patient #1's temperature was documented as 100.8 F. The medical record lacked documentation of a reassessment until 6/8/19 at 1900 hours, approximately 9 hours later. At that time, Patient #1's temperature was documented as 101.4 F. The next reassessment of Patient #1's temperature was on 6/9/19 at 0000 hours, approximately 5 hours later. At that time, Patient #1's temperature was documented as 100.6 F. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a temperature greater than 99.5 F.

On 6/8/19 at 1935 hours, Patient #1's heart rate was documented as 129 bmp. The medical record lacked documentation of a reassessment until 6/9/19 at 0200 hours, approximately 6 and half hours later. At that time, Patient #1's heart rate was documented as 122 bmp. The next reassessment of Patient #1's heart rate was on 6/9/19 at 1000 hours, approximately 8 hours later. At that time, Patient #1's heart rate was documented as 128 bmp. The next reassessment of Patient #1's heart rate was on 6/9/19 at 1200 hours, approximately 2 hours later. At that time, Patient #1's heart rate was documented as 224 bmp. The next reassessment of Patient #1's heart rate was on 6/9/19 at 1600 hours, approximately 4 hours later. At that time, Patient #1's heart rate was documented as 125 bmp. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a heart rate greater than 120 bpm.

On 6/10/19 at 1931 hours, Patient #1's blood pressure was documented as 143/119 mm Hg. The medical record lacked documentation of a reassessment until 6/11/19 at 0700 hours, approximately 11 and half hours later. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a diastolic blood pressure greater than 100 mm Hg.

On 6/17/19 at 1750 hours, Patient #1 was transferred to the Intensive Care Unit. The last documented assessment of the patient's vitals was on 6/17/19 at 0800 hours. At that time, Patient #1's blood pressure was 156/122 mm Hg. The medical record lacked documentation of any additional reassessments of Patient #1's vitals prior to their transfer to the Intensive Care Unit. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a diastolic blood pressure greater than 100 mm Hg.

4. Review of patient #2's medical record indicated the following:
(A) The patient was admitted on 6/11/19 at 2247 hours and discharged on 6/17/19 at 1800 hours.
(B) The patient had the following physician orders:

"...Vital Signs...Per unit policy...Start Date/Time 6/12/2019 02:57 [hours]...Stop Date/Time 6/20/2019 18:11 [hours]..."

"...Notify Provider Vital Signs...[Start Date/Time] 6/12/19 [at] 2:57 [0257 hours]..., Notify Psychiatrist and Adult Medicine Physician, HR greater than 120 bpm or, HR less than 50 bpm..."

"...Notify Provider Vital Signs...[Start Date/Time] 6/12/19 [at] 2:57 [0257 hours]..., Notify Psychiatrist and Adult Medicine Physician, SBP [systolic blood pressure] greater than 180 mm Hg or, SBP less than 90 mm Hg..."

On 6/14/19 at 2008 hours, Patient #2's blood pressure was documented as 181/76 mm Hg. The medical record lacked documentation of a reassessment until 6/15/19 at 0839 hours, approximately 12 and half hours later. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a systolic blood pressure greater than 180 mm Hg.

On 6/16/19 at 2004 hours, Patient #2's heart rate was documented as 136 bpm. The medical record lacked documentation of a reassessment until 6/17/19 at 0812 hours, approximately 12 hours later. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a heart rate greater than 120 bpm.

5. Review of patient #3's medical record indicated the following:
(A) The patient was admitted on 6/7/19 at 1610 hours and discharged on 6/25/19 at 1620 hours.
(B) The patient had the following physician orders:

"...Vital Signs...Per unit policy...Start Date/Time 6/7/2019 18:53 [hours]...Stop Date/Time 6/28/2019 17:10 [hours]..."

"...Notify Provider Vital Signs...[Start Date/Time] 6/7/19 [at] 18:53 [1853 hours]..., Notify Psychiatrist and Adult Medicine Physician, T greater than 99.5 F..."

On 6/12/19 at 2000 hours, Patient #3's temperature was documented as 100.2 F. The medical record lacked documentation of a reassessment until 6/14/19 at 0800 hours, approximately 36 hours later. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a temperature greater than 99.5 F.

On 6/23/19 at 2000 hours, Patient #3's temperature was documented as 100.4 F. The medical record lacked documentation of a reassessment until 6/24/19 at 0900 hours, approximately 13 hours later. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a temperature greater than 99.5 F.

6. Review of patient #5's medical record indicated the following:
(A) The patient was admitted on 6/3/19 at 1735 hours and discharged on 6/13/19 at 1112 hours.
(B) The patient had the following physician orders:

"...Vital Signs...Per unit policy...Start Date/Time 6/3/2019 22:54 [hours]...Stop Date/Time 6/16/2019 12:10 [hours]..."

"...Notify Provider Vital Signs... [Start Date/Time] 6/3/19 [at] 22:54 [hours]..., Notify Psychiatrist and Adult Medicine Physician, HR greater than 120 bpm or, HR less than 50 bpm..."

"...Notify Provider Vital Signs... [Start Date/Time] 6/3/19 [at] 22:54 [hours]..., Notify Psychiatrist and Adult Medicine Physician, DBP greater than 100 mm Hg..."

On 6/5/19 at 0741 hours, Patient #5's blood pressure was documented as 145/106 mm Hg and a heart rate of 125 bpm. The medical record lacked documentation of a reassessment until 6/5/19 at 2000 hours, approximately 12 hours later. At that time, Patient #5's blood pressure was documented as 137/110 mm Hg. The next reassessment was on 6/6/19 at 0741 hours, approximately 12 hours later. The medical record lacked documentation of Psychiatrist and Adult Medicine Physician notification as ordered for a diastolic blood pressure greater than 100 mm Hg or a heart rate greater than 120 bpm.

7. During an interview with A4 (Risk Manager) on 7/2/19 at 5:15 p.m., he/she verified that patients #1, 2, 3 and 5's medical records had a physician order to assess the patients' vitals per unit policy.

8. During an interview with A10 (Director of Clinical Outcomes/Infection Preventionist) on 7/2/19 at 6:08 p.m., he/she verified that the assessment of patient vitals were being completed inconsistently. A10 verified the patients' vitals were being assessed more toward the every 12 hours instead of every 6 hours as ordered per unit policy for patients #1, 2, 3 and 5. A10 verified that patient vitals that were out of the physician ordered parameters were not documented as being reassessed when noted to be out of the parameters for patients #1, 2, 3 and 5. A10 also verified that the Psychiatrist and Adult Medicine Physician were not documented to be notified as ordered when the patients' vitals were out of the ordered parameters for patients #1, 2, 3 and 5. A10 verified the medical record information for patients #1, 2, 3 and 5.

9. During an interview with A11 (Chief Nursing Officer) on 7/2/19 at 6:10 p.m., he/she verified that if a patient's vitals are out of the physician ordered parameters, he/she would expect an attempt to reassess the patient's vitals again within an hour.