The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MEMORIAL HOSPITAL 4500 MEMORIAL DRIVE BELLEVILLE, IL 62226 Nov. 25, 2015
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, it was determined in 1 of 10 (Pt #1) medical record reviewed, the Hospital failed to ensure patients were being reassessed per Hospital policy, potentially affecting all patients receiving care at the Hospital.
Findings include:

1. On 11/23/15 at 11:00 AM, the medical record of Pt #1 was reviewed. Pt #1 was admitted on [DATE] due to a newly diagnosed malignancy. The patient was transferred to another hospital on [DATE] at 5:59 PM. Documentation on the "Vital Signs" sheet indicated Pt #1 had a blood pressure recording of "92/50L" on 9/5/15 at 12:00 PM. There are no other recorded blood pressure readings, after 12:00 PM.

2. On 11/24/15 at 1:00 PM, the Hospital policy "General Assessment, Monitoring & Physical Care" effective 12/2014, was reviewed. Under "II. Policy: if blood pressure is abnormally high or low, it should be repeated in the opposite arm (in the absence of a contraindication) and compared to the initial reading."

3. On 11/24/15 at 10:40 AM, an interview with the telemetry nurse (E #9) was conducted. E #9 agreed that the vital sign sheet for Pt #1 did contain a reading of 92/50L and verbalized the "L" next to the blood pressure reading indicated the blood pressure reading was abnormally low. E #9 also verbalized that she was aware of the abnormal reading and the nursing technician, responsible for retaking the blood pressure, took another set of vitals on Pt #1, and it was within normal limits "The nursing technician failed to update the electronic medical record to reflect the repeated, blood pressure reading."