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Based on policy and procedure review, medical record reviews, and staff interviews, the nursing staff failed to assess and/or reassess vital signs according to hospital policy for 4 of 10 patients (#s 2, 4, 5, and 8).

The findings include:

Review on 11/09/2016 of the hospital's "Standards of Care, Progressive Care Unit" policy, reviewed 02/17/2016, revealed "... OBJECTIVE: ... To identify and respond to patient changes in condition. If SBP (systolic blood pressure) outside the range of 90-140 or DBP (diastolic blood pressure) outside the range of 60-90 take it manually. Tell the nurse of both readings immediately. ..."

1. Closed medical record review of patient #2 on 11/09/2016 revealed a History and Physical (H&P) by MD #1 on 11/02/2016 at 0859. Review of the H&P revealed the patient presented to the Emergency Department (ED) on 11/02/2016 and was admitted for complaints of shortness of breath, tightness in her chest, and diaphoresis (sweating). Review of the nursing documentation revealed RN #, registered nurse, was the primary nurse 11/04/2016 during the 7p-7a shift and RN #2 was assigned to the patient 11/04/2016 during the 7a-7p shift. Review of the nursing vital sign (VS) flowsheet dated 11/04/2016 revealed the following blood pressures (BP) recorded:

-199/107 at 0058 with reassessment at 0127 (~29 minutes later)
-197/119 at 0127 with reassessment at 0344 (~2 hours, 17 minutes later)
-180/109 at 0344 with reassessment at 0605 (~1 hour, 21 minutes later)
-161/100 at 0605 with reassessment at 0711 (~1 hour, 6 minutes later)
-173/109 at 0836 with reassessment at 1110 (~2 hours, 54 minutes later)
Continued review of nursing documentation for 11/04/2015 revealed no additional documentation from 0058-0747 regarding MD notification/consultation or of patient condition.

During an interview with RN #2 on 11/09/2016 at 1620 revealed she was the primary nurse for patient #2 on 11/04/2016 during the 7a-7p shift. The interview revealed she was the nurse who obtained the patient's 0836 VS resulting in a BP of 173/109. During the interview RN #2 revealed she did not recheck the patient's BP and that it should have been rechecked. Interview revealed hospital staff did not follow hospital policy.

Interview on 11/09/2016 at 1635 with CNM #1, clinical nurse manager, revealed any BP outside the range indicated in the policy should be rechecked manually. The interview revealed the BP should be rechecked immediately following the out-of-range results as it indicates a possible change in condition. During the interview CNM #1 revealed, "Blood pressures should have been rechecked and there should definitely be documentation." Interview revealed nursing staff failed to follow hospital policy.

2. Closed medical record review of patient #4 on 11/08/2016 revealed a H&P by MD #2 on 09/02/2015 at 2200. Review of the H& P revealed the patient presented to the ED on 09/02/2015 and was admitted for complaints of shortness of breath, general weakness with difficulty moving his extremities, noted hypotension, and diarrhea. Review of the ED nursing documentation revealed RN #3 was the primary nurse on 09/02/2015 during the 7a-7 p shift and RN #4 was assigned to the patient on 09/02/2015 7p-7a. Review of the ED Summary Report for 09/02/2016 dated 10/02/2015 at 0004 revealed the following BPs recorded:

- 92/51 at 1620 with reassessment at 1748 (~1 hour, 28 minutes later)
- 94/42 at 1748 with reassessment at 1838 (~50 minutes later)
- 95/51 at 1838 with reassessment at 2038 (~2 hours later)

An interview on 11/09/2016 at 1515 with CNM #2 revealed VS are required as part of the initial RN assessment in the ED. During the interview with CNM #2 she revealed there is no written policy regarding the frequency of VS or set parameters to indicate when VS should be rechecked. Continued interview revealed if a patient presents with no history of high blood pressure and the BP is elevated, nursing staff "would recheck and assess BP again." The interview revealed since the MD is present in the ED, conversation regarding the patient's status is ongoing and there may not be documentation indicating the physician is notified of a change in condition or VS that may be outside the patient's normal parameters. CNM #2 revealed reassessment criteria is individually based and depends on the patient's presentation and overall status. Further interview revealed given patient #4's status upon presentation, "My suspicion is yes, we should have documented more vital signs than what is recorded. Looking at this I would think we would've had more (VS) in there." Interview revealed hospital ED nursing staff failed to reassess the patient's VS.

3. Closed medical record review of patient #5 on 11/08/2016 revealed a H&P by MD #3 on 10/01/2016 at 1723. Review of the H&P revealed the patient presented to the ED on 10/01/2016 with productive cough producing small amount of blood-tinged sputum with and worsening chills. Continued review revealed the patient diagnoses included severe sepsis, acute on chronic respiratory failure, hypotension (low blood pressure), bacteriuria (UTI) and atrial fibrillation (irregular heart rate). Review of the nursing documentation revealed RN #5 was the primary nurse assigned to the patient on 10/01/2016 during the 7a-7p shift. Review of the nursing vital sign flowsheet dated 10/01/2016 revealed the following BPs recorded:

- 86/40 at 1450 with reassessment at 1535 by RN #6 (~45 minutes later)
- 89/58 at 1535 with reassessment at 1625 (~50 minutes later) by RN #7
- 93/52 at 1805 with reassessment at 2358 (~5 hours, 53 minutes later)
- 94/61 at 2358 with reassessment at 0302 (~3 hours, 4 minutes later)

During an interview on 11/09/2016 at 1635 the CNM #1 revealed any BP outside the range indicated in the policy should be rechecked manually. The interview revealed the BP should be rechecked immediately following the out-of-range results as it indicates a possible change in condition. Continued interview revealed, "Blood pressures should have been rechecked and there should definitely be documentation." Interview revealed nursing staff failed to follow hospital policy.

4. Open medical record review of patient #8 on 11/08/2016 revealed a H&P by MD #4 on 11/03/2016 at 0429. Review of the H&P revealed the patient presented to the ED on 11/02/2016 with complaints of abdominal pain. Continued review revealed the patient diagnoses included acute pancreatitis (inflammation of the pancreas), pneumonia, small bowel obstruction and diabetes. Review of the nursing documentation revealed RN #8 was the primary nurse assigned to the patient on 11/02/2016 during the 7p-7a shift. Review of the nursing vital sign flowsheet dated 11/02/2016 and 11/03/2016 revealed the following:

Temperature: 102.2 at 2128 with reassessment at 0121 (~3 hours, 53 minutes later)

Blood Pressure:
- 185/90 at 2144 on 11/02/2016 with reassessment at 0157 (~4 hour, 13 minutes later)
- 165/91 at 0157 taken by RN #10 with reassessment by RN #1 at 0601 (~4 hours, 4 minutes later)
- 185/87 at 0601

During an interview on 11/09/2016 at 1635 the CNM #1 revealed any BP outside the range indicated in the policy should be rechecked manually. The interview revealed the BP should be rechecked immediately following the out-of-range results as it indicates a possible change in condition. Continued interview revealed, "Blood pressures should have been rechecked and there should definitely be documentation." Interview revealed nursing staff failed to follow hospital policy.

Based on policy and procedure review, medical record reviews, and staff interviews, the nursing staff failed to update the plan of care according to hospital policy for 3 of 10 patients (#s 2, 4 and 6).

The findings include:

Review on 11/09/2016 of the hospital's "Plan of Care" policy, revised 03/17/2015, revealed, "POLICY: ...The plan will be reviewed by an RN and revised based upon patient needs for care. ... PLANNED REVIEW OF THE PLAN OF CARE: ...The RN will review the plan of care to determine if the diagnosis selected are consistent with the patient's condition and needs for care...."

1. Closed medical record review of patient #2 on 11/09/2016 revealed a History and Physical (H&P) by MD #1 on 11/02/2016 at 0859. Review of the H&P revealed the patient presented to the Emergency Department (ED) on 11/02/2016 and was admitted for complaints of shortness of breath, tightness in her chest, and diaphoresis (sweating). Continued review also revealed a history of "alcohol and benzodiazepine abuse". Review of the nursing assessment on 11/03/2016 at 2030 revealed, "Behaviors/Mood -Anxious" and again on 11/04/2016 at 0900. Review of the Medication Administration Record (MAR) for 11/03/2016 revealed Ativan 0.5 mg by mouth was given at 2033 for "anxiety/restlessness". Continued review of the MAR revealed Zyprexa 2.5 mg by mouth was given 11/04/2016 at 0300 for "Agitation". Review of the nursing vital sign for 11/04/2016 revealed blood pressures as follows:
-199/107 at 0058
-197/119 at 0127
-180/109 at 0344
-161/100 at 0605
-173/109 at 0836
Review of the Care Plan did not reveal interventions or goals for the management of the patient's anxiety.

An interview with the CC #1, clinical coordinator, on 11/09/2016 at 1430 during the medical record review revealed a care plan for anxiety should have been implemented. During the interview with CC #1 she revealed that once there was a change in the patient's need or status, a care plan should have been developed to address the patient care needs at that time. Interview with CC #1 revealed nursing staff did not follow hospital policy.

During an interview with RN #2, registered nurse, on 11/09/2016 at 1620 she revealed that she was the primary nurse for patient #2 on 11/04/2016 during the 7a-7p shift. RN #2 revealed the patient was well known to the nursing staff at the hospital and that she had a history of substance use. According to RN #2, the patient was "definitely anxious and upset about not getting IV Ativan". Continued interview with RN #2 revealed she was the nurse who obtained the patient's vital signs on 11/04/2016 at 0836 resulting in a BP of 173/109, which may have been related to anxiety. RN #2 revealed the nursing staff "usually just go with the first two diagnoses used to admit the patient" and that she did not consider adding "Anxiety" to the patient's plan of care. Interview with RN #2 revealed hospital nursing staff did not follow hospital policy.

An interview on 11/09/2016 at 1635 with CNM #1, clinical nurse manager, revealed care plans should be initiated when there is a change in the patient's condition or if nursing staff is actively treating a problem. CNM #1 revealed it is not acceptable practice to simply "pick the first two diagnoses used for admission" and omit other problems the patient may have.

2. Closed medical record review of patient #4 on 11/08/2016 revealed a H&P by MD #2 on 09/02/2015 at 2200. Review of the H& P revealed the patient presented to the ED on 09/02/2015 and was admitted for complaints of shortness of breath, general weakness with difficulty moving his extremities, noted hypotension (low BP), and diarrhea. Continued review of the H&P revealed the patient also presented with wounds and cellulitis in the RLE (right lower extremity). Review of the nursing assessment dated 09/03/2016 at 0830 revealed the patient had a draining wound on the right posterior calf, an incision wound to the right groin, and a partial thickness pressure ulcer on his coccyx (tailbone). Continued review of the assessment revealed the patient was followed by the wound care nurse who performed all treatments and dressing changes over the course of the patient's hospitalization. Review of the Care Plan did not reveal interventions or goals for the management of the patient's wounds.

An interview with CC #1 on 11/09/2016 at 1430 during the medical record review revealed a care plan for wounds should have been implemented. CC #1 revealed the patient presented with wounds identified as a problem on the nursing assessment and that just because it was not identified as problem by the physician on admission, did not negate nursing's responsibility of initiating a plan of care. Interview revealed nursing staff did not follow hospital policy.

During an interview on 11/09/2016 at 1635 with CNM #2 revealed care plans should be initiated when there is a change in the patient's condition or if nursing staff is actively treating a problem. The interview with CNM #2 revealed it is not acceptable practice to simply "pick the first two diagnoses used for admission" and omit other problems the patient may have. Interview with CNM #2 revealed nursing staff did not follow hospital policy.

3. Open medical record review for patient #6 on 11/08/2016 revealed a H&P by MD #2 on 11/02/2016 at 0008. Review of the H&P revealed the patient presented to the ED on 11/02/2016 and was admitted for complaints of a "large, foul-smelling sore on the right foot that has been present for 3 weeks" with drainage. Review revealed the patient's diagnoses included sepsis, diabetes, foot ulcer, and hypertension. Review of physician orders by MD #5 dated 11/03/2016 at 1059 revealed a wound consult. Continued review of the medical record revealed the initial wound consult was performed 11/04/2016 at 1040 by RN #12 with continued wound care during hospitalization. Review of the Care Plan did not reveal interventions or goals for the management of the patient's wounds.

An interview with CC #1 on 11/09/2016 at 1430 during the medical record review revealed a care plan for wounds should have been implemented. CC #1 revealed the patient presented with wounds identified as a problem on the nursing assessment and that just because it was not identified as problem by the physician on admission, did not negate nursing's responsibility of initiating a plan of care. Interview revealed nursing staff did not follow hospital policy.

During an interview on 11/09/2016 at 1635 with CNM #2 revealed care plans should be initiated when there is a change in the patient's condition or if nursing staff is actively treating a problem. CNM #2 revealed it is not acceptable practice to simply "pick the first two diagnoses used for admission" and omit other problems the patient may have. The interview with CNM #2 revealed nursing staff did not follow hospital policy.

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