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Based on the review of the medical records #1 and #2, a tour, staff interviews, policy and procedures, it was determined the allegation could be substantiated that the facility failed to ensure that one (1) of two (2) patients medical record #1 received a reassessment of vital signs as indicated by the facility policy. A deficiency was cited at A0395.

Review of the facility's policy, entitled "Emergency Center Assessment and Reassessment", dated 4-2009 revealed the patient would be reassessed and the information documented by the ECT (Emergency Room Technician) minimally every two (2) hours. Vital signs were defined as obtaining Blood pressure (normal - systolic 110-130, diastolic 70-90), heart rate (normal 60-100), respirations (normal 16-20), temperature (normal 98.6 degrees Celsius), pulse oximeter (normal 95- 100), and pain (1-10, 10 being the highest level of pain).

Review of the patient's #1 medical record documentation revealed the patient's vital signs (were taken on arrival at the ED (Emergency Department) at 11:43 a.m. The patient's blood pressure was documented at 12:00 p.m. as 102/75, p.m. The patient's next vital signs were documented at 3:10 p.m. with blood pressure at 93/50, and 85/45 at 4:21 p.m. The documentation in the record revealed vital signs were not taken between 12:00 p.m. and 3:10 p.m., a time span of 3 (three) hours and 10 (ten) minutes.

An interview was conducted on 3/26/13 at 11:40 a.m. in the classroom room with the Director of Emergency Service. The director stated the patients were assessment/reassessed by the nurse at least every 2 (hours). The director indicated when patients/family or anyone requesting to speak with the nurse, the nurse communicated with the person to let them know that someone would be with them as soon as possible/ The charge nurse (employee #8) did not communicate with the surveyor when he/she had came to the observe the ED and requested to speak with the charge nurse. The charge nurse should have followed up with the surveyor/observer to let him/her know that someone would be available to talk with them as soon as possible.

An interview (employee file #1) was conducted on 03/26/13 at 2:30 p.m. in conference room with the emergency room (ED) nurse who cared for the trauma patient. The nurse stated the trauma patient should receive his/her vital signs every 15 minutes for the first 30 minutes and then at least every 2(two) hours after that. The nurse indicated the ECT (Emergency Center Technician) assisted in completing vital signs for the patient and he/she would review that information. The nurse stated he/she was not contacted by the patient/family that the patient's blood pressure had dropped. The nurse explained the patient was assessed at least every 2 (two ) hours. The nurse explained the initial assessment on the patient was completed during the triage assessment at 11:43 a.m. when the patient first came to the ER. The nurse verbalized the following assessments for the patient were completed at 11:50 a.m., 12:41 p.m., 3:10 p.m., 3:12 p.m. and at 4:21 p.m. The nurse verbalized the patient was transferred to the unit at 5:45 p.m.

A memo dated 03/27/13 from the ED evening charge nurse (employee #1) who was not available for an interview indicated that he/she worked on the evening shift when the surveyor/observer presented to the ED and had spoken with the desk clerk that he/she wanted to speak with the charge nurse. The charge nurse told the ED staff that he/she was unable to speak with surveyor/observer because he/she was too busy but that he/she had had not communicated to the survey/observer that he/she would get someone else to assist him/her.

Tour of the emergency room on 03/25/12 at 6:00 p.m. the surveyor requested to speak with the charge nurse and the charge nurse told the ED staff person that he/she could not come and speak with the surveyor/observer because he/she was busy. The charge nurse failed to communicate alternative assistance for the surveyor/observer and had not discussed alternative means to assist the surveyor/observer.