HospitalInspections.org

Based on record review and interview, the facility failed to ensure RN supervision and evaluation of the nursing care for 1 of 3 (Patient #2) emergency room patients on 8/16/15, in that, Patient #2 did not have a nursing assessment documented and/or vital signs documented for 3 hours in the emergency room.

Findings Included

Patient #2 was brought via ambulance to the emergency room for abdominal pain and shortness of breath at 9:27 AM on 8/16/15 and placed in Room 7.

Patient #2's medical record did not document in the first three (3) hours of being in Room 7, a nursing assessment of the respiratory system or the abdomen.

Patient #2's medical record did not document vital signs for three (3) hours on 8/16/15 from 9:30 AM through 12:45 PM.

Patient #2's medical record documented Morphine was given at 9:52 AM.

Patient #2's medical record did not document vital signs after medication administration that affects the hemodynamic status.

Patient #2's medical record did not document a recheck of abnormal vital signs.

During an interview and record review on 1/28/16 ending at 9:40 AM, Personnel #13 was informed of the above findings. Personnel #13 was asked if the findings were correct. Personnel #13 stated, "Yes."

The facility's May 2010, last reviewed, Emergency Services "Assessment and Reassessment of Patients" policy required, "should be assessed for physical, psychological and social status to identify patient's care needs...assessment should be initiated in a timely manner after the patient is placed in the treatment area. The scope and intensity of this assessment is determined by the patient's condition, complaint/diagnosis...monitored and assessed at regular intervals as patient condition indicated...significant changes in condition...patient reassessments will be done in a time frame appropriate for the patient's condition...In addition, vital signs (blood pressure, pulse, respirations, and temperature) should be monitored...during initial assessment on all patients...Abnormal vital signs should be rechecked as indicated by the patient's condition...Vital signs should be taken at least every 15 - 30 minutes if patient has been administered medication that affects the hemodynamic status..."