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Based on policy review, record review and interview, clinical staff did not implement the sepsis screening protocol per policy for Patient #1. A complete set of vital signs was not obtained for 13 of 20 patients (Patient #1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #16, #19, and #20) during triage and/or during the emergency department (ED) visit per policy. Failure to follow assessment policies can potentially delay or prevent needed treatment interventions.
Findings include:

Review of policy "Severe Sepsis Protocol " dated 01/20/16 revealed patient screening and identification includes the presence of two or more signs of systemic inflammatory response syndrome: core temp of greater than 101.0 or less than 96.8, heart rate greater than 90 beats/min, respiratory rate greater than 20, white blood count greater than 12,000/mm or less than 4,000/mm, acutely altered mental status and a plasma glucose greater than 120 in the absence of diabetes. A registered nurse (RN) that suspects a patient may have signs and symptoms of an infection will initiate the " severe sepsis screening tool " , including STAT lab work and cultures. Additional screening for organ dysfunction includes a systolic blood pressure less than mmHg, bilateral pulmonary infiltrates with new or increased oxygen requirement to maintain SpO2 greater than 90% or a PaO2/FiO2 ratio less than 300.

Review of ED record dated 06/20/16 revealed Patient #1 presented to the ED at 06:24 AM with shortness of breath. Vital signs at 06:58 AM revealed a blood pressure (BP) 109/65, pulse (P) 121 respiratory rate (RR) 28. No documentation of temperature is noted. From 07:15 AM to 10:35 AM the pulse readings ranged from 105 to 120 and respirations ranged from 20 to 29. At 08:26 AM the blood pressure (BP) dropped to 63/49. At 10:01 AM the physician diagnoses Patient #1 with pneumonia and a urinary tract infection (UTI).
No evidence was found to indicate the severe sepsis protocol was implemented despite Patient #1 ' s elevated pulse & respirations, hypotension and diagnosis of an UTI and pneumonia requiring oxygen administration (new).

Review of policy NUR-D-006 "Documentation Form Required for Emergency Department Patients" last revised 10/23/15 indicates vital sign documentation should include a temperature.

Review of policy NUR-ED-T-002 "Emergency Department Triage" last revised 9/30/2015 indicates every patient entering the Emergency Department will have a complete set of vital signs taken.

Review on 09/22/16 of Patient #1, 2, #3, #4, #5, #6, #8, #9, #10, #11, #16, #19, and #20 revealed no evidence of documentation that a temperature was obtained at triage or during their emergency department visit.
Interview on 09/22/16 at 8:46 AM with Staff #1 and at 10:30 AM with Staff #4 confirmed that a complete set of vital signs includes a temperature. Staff #4 stated vital signs are completed at triage and depending on acuity.
Interview on 09/23/16 at 10:00 AM with Staff #1 confirmed these findings.