HospitalInspections.org

Based on interview and record review, the hospital failed to adhere to policy for two of 21 sampled patients (Patients 1 and 27) when there was no documentation that the licensed nurses notified the doctor when the patients' blood pressures fell below specified parameters. This failure had the potential to result in delayed implementation of interventions.

Findings:

1. Review of Patient 1's medical record indicated he was admitted on 3/28/25 and had diagnoses including tonsillar hypertrophy (enlarged tonsils), sleep disordered breathing, and snoring. The medical record further indicated Patient 1 had a tonsillectomy (surgical removal of the tonsils) on 3/28/25.

Review of Patient 1's document titled "Notify MD [doctor of medicine]/APP [advanced practice provider] (VS [vital signs] Parameters)" indicated Patient 1 had an order, dated 3/28/25, to notify the doctor if the patient's systolic blood pressure (SBP, the top number in a blood pressure reading) was below 90 or if the patient's diastolic blood pressure (DBP, the bottom number in a blood pressure reading) was below 50.

Review of Patient 1's Flowsheet History indicated Patient 1's blood pressure fell below the specified parameters on 3/29/25 at 10:00 a.m., 11:00 a.m., 12:00 p.m., and 4:00 p.m. There was no documentation that the doctor was notified.

During an interview with Patient Care Manager A (PCM A) on 5/8/25, at 11:44 a.m., PCM A explained the bedside nurses were responsible for monitoring patients' vital signs and reporting to the doctor.

During an interview and concurrent record review with Clinical Informatics Project Manager B (CIPM B), Clinical Nurse Specialist C (CNS C), Nursing Professional Development Specialist D (NPDS D), and Patient Safety Advisor E (PSA E) on 5/12/25, at 12:52 p.m., Patient 1's medical record was reviewed. CIPM B, CNS C, NPDS D, and PSA E confirmed some of Patient 1's blood pressures fell below specified parameters and there was no documentation that the doctor was notified.


2. Review of Patient 27's medical record indicated she was admitted on 5/8/25 and had a cesarean section (C-Section, a surgical procedure used to deliver a baby through an incision [surgical cut] in the mother's abdomen and uterus).

Review of Patient 27's document titled "Notify MD/APP (VS Parameters)" indicated Patient 27 had an order, dated 5/8/25, to notify the doctor if the patient's SBP was below 90 or if the patient's DBP was below 60.

Review of Patient 27's Flowsheets indicated her blood pressure fell below the specified parameters on 5/8/25 at 8:42 p.m., 11:00 p.m., and 11:05 p.m. The Flowsheets also indicated Patient 27's blood pressure fell below the specified parameters on 5/10/25 at 8:26 a.m. There was no documentation that the doctor was notified.

During an interview and concurrent record review with Clinical Informatics Project Manager F (CIPM F) and Clinical Practice Quality Specialist G (CPQS G) on 5/12/25, at 10:37 a.m., Patient 27's medical record was reviewed. CIPM F confirmed some of Patient 27's blood pressures fell below specified parameters and there was no documentation that the doctor was notified. CPQS G confirmed these blood pressures should have been reported to the doctor.

The hospital's policy titled "Documentation - Nursing," revised 4/2025, indicated, "For any abnormal or worsening vital signs, physical assessments, or sings or symptoms, the provider must be notified. Document the provider notification in the EHR [electronic health record] under Provider Notification."