HospitalInspections.org

Based on medical record review, interviews and document review, it was determined the facility failed to monitor vital signs for six (6) of eight (8) patients, according to the facility policy.

The findings include:

During medical record review, the afternoon of August 18, 2025 and the morning of August 19, 2025, with Staff Member 2 and Staff Member 21, the surveyors determined that six (6) of eight (8) medical records reviewed during the survey process did not contain evidence of vital sign monitoring, according to the facility policy.

The emergency department (ED) medical records evidenced the following vital sign monitoring:

Patient 1- ESI (Emergency Severity Index) 2- November 20, 2024: 1:03 PM, 3:30 PM, and 6:00 PM (Patient 1 was admitted to this facility on November 20, 2024 at 8:04 PM)
Patient 2- ESI 3- November 21, 2024: 12:37 PM and 4:36 PM (Patient 2 was discharged from this facility on November 21, 2024 at 6:53 PM)
Patient 3- ESI 3- November 21, 2024: 3:51 PM, 9:34 PM, and 11:34 PM (Patient 3 was discharged from this facility on November 21, 2025 at 11:35 PM)
Patient 6- ESI 2- April 26, 2025: 10:45 AM, 1:00 PM, 2:31 PM, 3:32 PM and 7:53 PM (Patient 6 was admitted to this facility on April 26, 2025 at 7:52 AM)
Patient 7- ESI 2- April 14, 2025: 11:59 AM, 2:45 PM, 3:15 PM, 4:37 PM, and 8:16 PM (Patient 7 was admitted to this facility on April 14, 2025 at 12:10 PM)
Patient 11- ESI 2 August 18, 2025: 11:20 AM, 12:00 PM, 3:03 PM, 5:01 PM, 6:44 PM, and 7:30 PM (Patient 11 was admitted to this facility August 18, 2025 at 7:32 PM)

During an interview with Staff Member 8, on August 19, 2025 at 10:15 AM, when the surveyor asked about ED vital sign monitoring, Staff Member 8 indicated that a patient with an ESI level of two (2) would be monitored within every hour and an ESI three (3) would be monitored within every two (2) hours.

During an interview with Staff Member 9, on August 19, 2025 at 10:30 AM, when the surveyor asked about ED vital sign monitoring, Staff Member 9 indicated that a patient with an ESI level of three (3) would need to be monitored every two (2) hours and the ED technicians are the ones who usually obtain these vital signs .

A facility policy, Emergency Care and Treatment, last revision January, 2019, revealed in part, "...f. Patients who remain in the waiting area or triage area after initial assessment and prior to admission or treatment area are re-evaluated by a nurse, paramedic, or EMT (Emergency Medical Technician). The guidelines for completion or re-evaluation are within the following time frames: 1. ESI LEVEL 1: Every 15 minutes 2. ESI LEVEL 2: Every hour 3. ESI LEVEL 3: Every 2 hours 4. ESI LEVEL 4: Every 4 hours 5. ESI LEVEL 5: Every 4 hours."