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Based on interview and record review, facility staff failed to complete vital sign monitoring for discharge per facility policy in 4 of 10 medical records (Patients #1, 4, 5, 6,) reviewed in a total sample of 10 medical records reviewed.

Findings Include:

A review of the facility's policy titled, "Emergency Department Standards of Care" last revised 07/03/2024 revealed, "... Discharge of Patients from ED (Emergency Department): ... 4. VS (vital signs) must be taken within one hour of discharge."

A review of Patient #1's medical record revealed Patient #1 presented to the facility's ED on 07/25/2024 at 11:29 AM. Patient #1's vital signs were taken on 07/25/2024 at 12:40 PM. Patient #1 was discharged from the ED on 07/25/2024 at 3:36 PM (approximately 3 hours after the last set of vital signs were obtained).

A review of Patient #4's medical record revealed Patient #4 presented to the facility's ED on 07/24/2024 at 4:05 PM. Patient #4's vital signs were taken on 07/24/2024 at 4:24 PM. Patient #4 was discharged from the ED on 07/24/2024 at 7:06 PM (approximately 2.5 hours after the last set of vital signs were obtained).

A review of Patient #5's medical record revealed Patient #5 presented to the facility's ED on 07/25/2024 at 1:09 PM. Patient #5's vital signs were taken on 07/25/2024 at 1:25 PM. Patient #5 was discharged from the ED on 07/25/2024 at 3:24 PM (approximately 2 hours after the last set of vital signs were obtained).

A review of Patient #6's medical record revealed Patient #6 presented to the facility's ED on 07/25/2024 at 4:05 PM. Patient #6's vital signs were taken on 07/25/2024 at 4:24 PM. Patient #6 was discharged from the ED on 07/25/2024 at 6:08 PM (approximately 2 hours after the last set of vital signs were obtained).

An interview was conducted on 08/27/2024 at 10:48 AM with Manager of Quality M who stated, "Per policy there should be VS taken within 1 hour prior to d/c (discharge)."