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.


Based on medical record review, staff interviews, and facility policies, the facility failed to follow policies and procedures related to obtaining vital sign assessment of one of ten patients reviewed (Patient #4).

Findings include:

A medical record review of Patient #4 was conducted during this visit. The medical record revealed the patient resided in a group home with caregivers present. On the morning of 03/20/12, this patient was brought by emergency squad to this facility's emergency department (ED) for evaluation of a possible stroke. The patient was triaged in the ED on 03/20/12 at 5:29 AM, with an arrival complaint of right sided weakness, and was determined to be a Level 2 acuity, which was considered not life-threatening. The medical record documented Patient #4 had diagnoses of [DIAGNOSES REDACTED]

During the course of this visit, the attending physician ordered a CT scan without contrast and lab work as follows: seizure medication level, a complete blood count with differential, and a basic metabolic panel. These laboratory levels were obtained within eighteen minutes after ordered. The only abnormal laboratory result was an elevated blood glucose of 120 (normal 70-100). The CT scan was completed at 6:38 AM for signs and symptoms of [DIAGNOSES REDACTED]
The findings documented no intracerebral hemorrhage or acute infarct. The impression was ventriculomegaly (enlargement of ventricles of the brain with no known cause) consistent with [DIAGNOSES REDACTED]).

According to the attending physician's note, dated 03/20/12 at 7:20 AM, Patient #4 presented with some mental status changes, was nonverbal, and had mental impairment. The physician documented Patient #4 did not react to interact or respond to voice or pain, typically ambulates with difficulty but apparently about 4:00 in the morning got up and was leaning towards the right side.

The physician documented the SP's blood pressure was 138/91, pulse 89, respirations 16, and temperature 97.6 degrees Fahrenheit (F). This was verified in the medical record as being obtained at 6:48 AM.

Per medical record documentation, the patient's initial vital signs were recorded at
5:31 AM and were 128/91 (blood pressure), pulse was 89, respirations were 18 per minute, and temperature was 97.6 degrees F. The medical record was silent to vital sign assessment of Patient #4 after 6:48 AM. The patient remained in the ED until discharge with the caregiver to home at 8:16 AM on 03/20/12. The registered nurse documented the patient was alert, skin warm, dry and pink. A licensed practical nurse accompanied the patient at that time, and denied needs and questions.

Based on facility policy and medical record documentation, vital sign assessment should be obtained hourly and one hour prior to discharge for a patient with a Level 2 acuity. A review of the ED's Patient Care Guidelines and Documentation Policy, on 08/29/12, revealed for a Level 2 acuity, frequent vital re-assessment not to exceed 1 hour based on patient condition should be completed. This policy also stated vital signs must be completed no more than 1 hour prior to discharge. This was verified by Staff N (attending physician) and Staff I (ED nurse manager) on 08/29/12 at 4:00 PM.

According to an interview with the complainant, during this visit, the patient was discharged from this facility's ED, and taken to a different hospital (hospital #2) immediately after discharge. The complainant stated the reason was the caregiver was not comfortable with the patient's status, and contacted the group home's supervisor. That supervisor directed the caregiver to take the patient to a different hospital for evaluation. Hospital #2's medical record, for the patient, revealed an arrival to the ED in a car at 8:48 AM on 03/20/12. The final diagnoses was altered mental status, and other malaise and fatigue.

On 03/20/12, at 8:00 PM, the patient was discharged from Hospital #2 and was taken by emergency squad to Hospital #3, where the patient was admitted to intensive care for EEG monitoring. Hospital #3's medical record of the patient revealed the patient arrived at 8:51 PM at 03/20/12 and admitted to the medical intensive care unit (MICU). The reason for admission was listed as acute [DIAGNOSES REDACTED]. The patient expired at Hospital #3 on 03/21/12 at 9:28 AM.