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Based on hospital policy review, medical record review, physician and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

Based on review of medical records, facility guidelines, and interviews with staff, the facility failed to ensure vital signs were reassessed and reported to the provider responsible for completing the medical screening exam for one of 20 patients (Patients (P) 20). This lack of clinical information could potentially delay the determination of an Emergency Medical Condition.

Cross Refer to A2406.

Based on a review of medical records, waiting room and triage guidelines, and interviews with staff, the hospital failed to ensure vital signs were reassessed and reported to the provider responsible for completing the medical screening exam for one of 20 patients seen in the Emergency Department (Patients (P) 20). The patient had been triaged as higher acuity patient. This lack of clinical information could potentially delay the determination of an Emergency Medical Condition.

Findings include:

Review of weekly Emergency Department (ED) Huddle Meetings showed a daily dashboard review of admissions to the ED for the week of 07/19-07/25/2024. Included in the minutes was an ED Update Reminder that stated, "Please review vital sign expectations." An undated document titled, "Why are vital signs important in the Emergency Department," was included in the Huddle record. This document stated, "Subtle changes in vital signs are often a prelude to patient deterioration and when identified, help prevent further deterioration. This is why it's important to: obtain a baseline set of vital signs on arrival . . . Monitor vital signs at frequent intervals and make sure to document them. . .All abnormal vital signs should be reported to the provider, and this should be documented. You should always be aware of your patient's vital signs and be able to identify any changes." Under the section, "How often should vital signs be done and documented," it was stated, "While in the waiting areas. . .they need to be done hourly. While in a patient care area, the frequency of vital signs is dependent on the patient's ESI [Emergency Severity Index is a tool for ranking acuity on a scale from 1-5 with 1 being most acute], any drips, and nursing judgement." The document included times for ESI levels as, "ESI 1-every 5-15 minutes until stable and then no more than every 30 minutes; ESI 2 at least every 30 minutes to 1 hour (but could be every 5, 10, or 15 minutes); ESI 3 no less than every 2 hours; ESI 4 and 5 can be less frequent but MUST be done at least every 4 hours and at discharge."

Patient 20 arrived in ED on 09/11/24 at 2:01 PM with complaints of chest pain. The ESI at triage was level 2 (vital signs at least every 30 minutes to one hour). The patient had initial vital signs at 2:17 PM, 4:13 PM, and not again until 10:00 PM. Vital signs were then repeated every half hour. The B/P at 2:17 PM was 192/67. The B/P at 4:13 PM was 201/82. The B/P at 22010:00 PM was 172/59. All B/P results were elevated, and the medical record showed no documentation of reporting to RN or ED provider staff or documentation of interventions for elevated B/P. The patient was subsequently entered into observation services with a diagnosis of hypertensive urgency.

During interview with the ED Nurse Manager on 10/30/24 in the conference room at 10:33 AM, the surveyor asked about the document, "Why are vital signs important in the Emergency Department?" The ED Nurse Manager acknowledged that she had gone over it in a Huddle meeting and given it to all nursing staff as guidelines for them to follow. When asked if it were her expectation that the staff would follow the guidelines, she stated that it was her expectation, but it really depended on the acuity of the patient. The ED Nurse Manager further stated that it was not always possible to achieve the timelines, and she audited some charts for timeliness of vital signs but was unable to audit all. Further stated that the expected practice was for the technicians to take hourly vital signs on patients in the waiting room. When asked about reporting abnormal vital signs, she said those should be reported to the triage or charge nurse by the technician.