HospitalInspections.org

Based on record review and interview, nursing staff failed to ensure that vital signs were obtained and recorded for 3 of 6 patients (patients #1, #2, #3) reviewed on this survey. Findings are:

-Review of patient #1's medical record completed on 3/8/2022 indicates that nursing service staff did not document a body temperature reading for patient #1 when he presented at emergency department triage on 9/6/2021 at 0128. The first temperature reading for patient #1 was 99.9 degrees documented at 0434.

-Review of patient # 2's medical record completed on 3/15/2022 indicates that nursing service staff did not document a body temperature reading for patient #2 when she presented at emergency department triage on 2/1/2022 at 0916.

-Review of patient # 3's medical record completed on 3/15/2022 indicates that nursing service staff did not document a body temperature reading for patient #3 when he presented at emergency department triage on 12/20/2022 at 0707.

-The ED Nurse Manager verified the finding for patient #1 during the survey on 3/8/2022 at 1030. The ED Nurse Manager verified the findings for patients #2 and #3 during a telephone interview completed on 3/30/2022 at 1130.

It is expected standard of practice that a body temperature be obtained from patients during their assessment at triage.

-Review of the hospital policy entitled "Standards for Patient Care Emergency Department, Section 1.1.1, conducted on 3/23/2022 revealed that "The primary nurse will complete a full assessment within 30 minutes of the patient's arrival to the examining room, ..... and that assessment will include identification of vital signs.