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|TEXAS VISTA MEDICAL CENTER||7400 BARLITE BLVD SAN ANTONIO, TX 78224||June 29, 2017|
|VIOLATION: CONTENT OF RECORD - OTHER INFORMATION||Tag No: A0467|
|Based on record review, interview and review of hospital policy the hospital failed to meet the requirement to ensure that all records documented vital signs to monitor the patient's condition because the medical record for P1 who was on medication for a history of hypertension did not have documentation that a blood pressure had been taken on 06/24/16 by the 7:00 a.m. to 7:00 p.m. shift.
Review of the medical record for P1 on 06/20/17 beginning at 3:30 p.m. in the boardroom revealed the following in part:
1. The patient was admitted for surgery on 06/22/16 and was on Clonidine for a long history of hypertension.
2. 06/22/16 at 11:46 a.m. Post-op orders included Labetalol 10 mg IV q 4h PRN (as needed) for a systolic blood pressure greater than 160 mmHg or diastolic blood pressure greater than 100 mmHg (Hold for HR less than 70 bpm).
3. The patient was given the following medications for blood pressures on the dates below:
06/22/16 at 13:30 - BP 191/94. At 13:49 - Labetalol 10 mg IV given. The physician was notified and gave orders for a Clonidine patch.
06/22/16 at 20:14 - BP 211/101. Labetalol 10 mg IV given.
06/22/16 at 22:42 - BP 199/102. Hydralazine 25 mg IV given per orders by a physician assistant at 22:28. Orders - Hydralazine Inj 25 mg IV q 6 h prn. Indication: HTN.
06/23/16 at 04:52 - BP 186/75. Hydralazine 25 mg given.
06/23/16 at 16:40 - BP172/80. "BP med given." 16:58 - Medication administration record - Labetalol 10 mg IV given.
06/24/16 at 04:15 - BP 172/98. Labetalol 10 mg IV given.
06/24/16 at 06:00 - BP 154/92.
4. The blood pressure section on the Vital Signs Report for 06/24/16 at 7:40 a.m. and 11:40 a.m. were blank.
5. A flowsheet dated 06/24/16 at 16:57 noted in part, "Pt Dschrg'd via: Wheelchair. Pt left AMA. Dr._ & Dr. _ aware. Pt told to contact Dr. if signs and/or symptoms occur."
In an interview on 06/29/17 at 11:08 a.m. in an office, S2 and S16, according to both S2 and S16, vital signs are taken twice a shift, shifts are 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. After review of the medical record with S2 and S16, both S2 and S16 acknowledged that the last documented blood pressure taken on 06/24/16 was at 06:00. Neither S2 or S16 could find documentation in the medical record that a blood pressure had been taken on 06/24/16 on the 7:00 a.m. to 7:00 p.m. shift. According to both S2 and S16 there should have been at least one blood pressure documented for the patient on 06/24/16 on the 7:00 a.m. to 7:00 p.m. shift. Both S2 and S16 confirmed there was documentation in the medical record on 06/24/16 at 7:40 a.m. and 11:40 a.m. that included a temperature, pulse, respirations and O2 sat and an entry that stated, "RN _ doing BP."
Review of the hospital policy entitled, "Assessment of Vital Signs," in an office on 06/29/17 at 11:30 a.m. revealed the following:
Vital signs are defined as the recording of a patient's temperature, blood pressure, pulse and respirations.
For assessment of vital signs of the patient, the nursing staff will record vital signs at the designated times.
1. Vital signs will be assessed and recorded as follows:
c. Med Surg/Telemetry/Bariatrics/Joint Center - Twice in a 12
2. Vital signs are recorded on graphic sheet and computerized nurse's
3. Any abnormalities will be reported immediately to the Registered
Nurse, Charge Nurse, and the physician.
4. Vital signs will be recorded at other times as designated by the
physician's orders or as needed in the nurse's judgment.