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.
|RANDOLPH HOSPITAL||364 WHITE OAK STREET ASHEBORO, NC 27204||Jan. 6, 2016|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of hospital policy and Standards of Patient Care, medical record review, and staff interview, hospital nursing staff failed to reevaluate a patient's vital signs per hospital policy in 1 of 10 Emergency Department patients reviewed (Patient #3).
The findings include:
Review of hospital policy titled, " Vital Sign Documentation by Nursing Assistant (CNA) (Certified Nursing Assistant) " , Last Review Date: February 19, 2014, revealed, " ... II. Procedure: A. BP (Blood Pressure) Card will be provided to CNAs as a standard reference of measurement. ADULTS: SBP (Systolic Blood Pressure - the pressure exerted on the circulatory system when the heart contracts) < (less than) 100 > (greater than) 140. HR (Heart Rate) < 60 > 100 ... "
Review of Standards of Patient Care Emergency Department, Effective Date: July 22, 2014, revealed, " ... B. Emergency Severity Index (ESI): Triage Classification and Reassessment Guidelines ... 3. Level III (3) ... Reassessment occurs at a minimum, every 3 hours or more often as condition warrants ... Unstable vital signs are repeated every 30 minutes until stable, then hourly x (times) 1, and every 4 hours thereafter, or more frequently as condition warrants ... "
Closed medical record review revealed Patient #3 was a [AGE] year old male who (MDS) dated [DATE] at 1038, requesting inpatient detoxification treatment for alcohol abuse. Review revealed Patient #3 was triaged by Registered Nurse #1 on 12/28/2015 1047, who designated him an ESI Level III, and performed a vital sign assessment which read, " ... BP 169/102 (high); HR 132 (high)... " Review revealed no further vital sign assessments were performed during the duration of Patient #3' s admission to the Emergency Department. Patient #3 was discharged on [DATE] 1220.
Staff interview with Administrative Staff #1 revealed no other vital sign assessments were performed on Patient #3 after triage, and Emergency Department Standards of Patient Care were not followed.