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Based on review of hospital emergency department standards of patient care review, closed medical record review, staff, physician's assistant and physician interview, hospital staff failed to assess vital signs at discharge for 1 of 2 patients (Patient #4) that received high blood pressure medication during an emergency department admission.

Findings included:

Review of Standards of Patient Care Emergency Department (no effective date) revealed, " ...Vital Signs Guidelines ... vital signs ... blood pressure ... ESI (Emergency Severity Index, a method of assigning a value to which patient presenting to an emergency department [ED] are prioritized) 1, 2, and 3 patients will have vital signs retaken at discharge ..."

Closed medical review revealed Patient #4 was a 53-year-old male that presented to the ED on 05/16/2018 at 1146 complaining of chest pressure and high blood pressure (BP) for 2 days and was assigned an ESI level of 3. Patient #4's blood pressure at 1243 was 186/121. At 1243, his BP increased to 265/155. At 1318 Patient #4 was given 20 mg (milligrams) of Labetalol (a medication to lower the BP) intravenously under orders from Physician's Assistant (PA) #1. Patient #4's BP at 1334 was 148/84. At 1732 Patient #4's BP was 192/114, and he was administered Hydralazine (a medication to lower the BP) 25 mg by mouth at 1744. Patient #4 was discharged from the ED by Registered Nurse (RN) #1 on 05/16/2018 at 1808, with no repeat blood pressure assessment.

Telephone interview was conducted on 08/22/2018 at 1026 with RN #1, who vaguely recalled Patient #4. Interview revealed RN #1 could not recall whether Patient #4's BP was assessed upon discharge.

Telephone interview was conducted on 08/22/2018 at 1000 with PA #1, who recalled Patient #4. Interview revealed despite Patient #4's BP increasing after the initial treatment with Labetalol, he remained asymptomatic. Interview revealed PA #1 did not recall any report from hospital staff regarding a repeat BP assessment after the Hydralazine administration, or at the time of discharge.
Interview was conducted on 08/22/2018 at 1552 with the ED Director, who confirmed the ED Standards of Patient Care regarding assessing vital signs at discharge was not followed.

NC00141561