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Based on clinical record review, staff interviews and policy review it was determined the facility failed to ensure that nursing evaluated the care on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy for (#1, and #2) of 10 patients selected for review
Findings included:
#1) - Patient #1 was triaged at 12:02 p.m. on 3/9/11. Her vital signs were temperature 100.9, respiration 20, blood pressure 145/64, oxygen saturations of 93% on room air, and a pain level of 10 out of 10. The patient received Tylenol 1000 milligram (mg) by mouth at 1:59 p.m. for the triage temperature of 100.9. The next set of vital sign was documented at 2:18 p.m. pulse 86, respiration 26, and oxygen saturation of 99%. There was no follow-up temperature in the ED prior to admission at 4:55 p.m.

On 3/9/11 at 8:00 p.m. and 3/10/11 at 12:00 a.m., the patient complained of nausea and vomiting and requesting medications. The nursing documentation for 3/10/11, preformed at 12:59 a.m., revealed that phone calls had been made to the Physician's answering service and cell phone three times with no call back from the Physician.

A review of the Physicians orders revealed telephone orders were written on 3/10/11 at 5:15 a.m. for anti emetic medications for the patient. The patient was medicated at 5:37 a.m. for nausea.

The patient was admitted to the Medical/Surgical Unit at 4:55 p.m. with an initial set of vital signs of pulse 69, blood pressure 93/55, and oxygen saturations of 95% on room air. The next temperature obtained, was 98.5 at 8:07p.m.

A review of the patient's vital signs for the duration of the stay revealed the vital signs were not consistently obtained as per the facility ' s policy. The patient ' s vital signs were obtained from 3 hours apart to 13 hours apart. According to the facility's policy the vital signs are listed as part of the assessment and should be obtained every 8 hours. On 3/15/11, the date of discharge, the patient was assessed and vitals were obtained at 6:00 a.m. but, they were not repeated prior to the patients discharge at 4:22 p.m., 10 ? hours later.

#2) Patients #2 was admitted on 3/23/11. The patient's vital signs were obtained on 3/23/11 at 8:00 p.m. and then 10 hours later at 6:02 a.m. on 3/24/11. On 3/24/11 the vital signs were also obtained at 3:54 p.m. and then 14 hours later at 6:04 a.m. on 3/25/11. The patient was assessed by nursing on 3/29/11 at 9:48 a.m.; vital signs were obtained at 2:49 p.m. and the patient was discharged home 9 hours later at 7:04 p.m. with no further assessment or vital signs documented.

An interview was conducted on 5/4/11 at 11:00 a.m., with the Director of Nursing (DON). When the DON was questioned as to the process for nursing to follow when unable to reach the Physician, she responded, that at the time of this incident there was no process in place, but since then, the facility has implemented a chain of command reporting so that nursing can reach the Physicians to obtain orders. When questioned on how often the patient's vital signs are obtained, the DON responded the vital signs are considered part of the assessment and should be obtained every 8 hours.

An interview was conducted on 5/3/11 at 4:45 p.m., with an ED nurse. When the nurse was questioned as to the process followed for a patient presenting with an elevated temperature, the nurse responded patients are medicated when the temperature is 100.5 or above and then a repeat temperature is taken 1 hour later to make sure the medication was effective.

A review of the policy "Patient Care Process", policy # 100.185.74, effective date 8/2009, page 1 of 3, revealed the following policy for assessment/reassessments. All patients will be assessed within 8 hours of admission to the Medical/Surgical Unit and reassessed every 8 hours afterwards and every 2 hours in the ED or sooner.