HospitalInspections.org

Based on policy review, medical record review, and staff interviews the hospital staff failed to document patient vital signs for 9 of 17 patients on 02/28/2021 during evening shift from 1900-0700. (Patients #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, and Patient #19)

Review of hospital policy titled "Clinical Documentation Guidelines" last revised 09/20218 revealed "Purpose To provide standards for clinical staff on proper documentation methods and use of forms...ll. What to Document in the Medical Record...A. Patient Assessment...4. Vital signs are assessed for every patient upon admission and daily, every 4-8 hours and as ordered by the physician or indicated by patient status..."

Review of hospital policy "Organized Nursing Staff" effective date 10/08/2015 revealed "...A registered nurse provides or supervises the nursing services 24 hours a day, 7 days a week."

1. Closed medical record review of Patient #11, an 80-year-old male admitted on 02/20/2021 for intravenous antibiotics due to an infected right hemiarthroplasty (surgical procedure replacing half of the hip joint) MRSA (methicillin-resistant staphylococcus aureus). Review of Admission Orders dated 02/10/2021 at noon revealed "Vital Signs q (every) 4 hrs. (hours)" by Nurse Practitioner (NP) #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 0400 vital signs were not documented by Certified Nursing Assistant (CNA) #1, or Registered Nurse (RN) #1.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer (CNO) #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet to document vital signs, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the Registered Nurse's (RN) to follow up and to ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) had documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

2. Closed medical record review of Patient #12, a 74-year-old female admitted on 02/15/2021 for acute hypoxic respiratory failure (don't have enough oxygen in your blood). Review of the Admission Orders dated 02/15/2021 at 1730 revealed "Vital Signs: q 4 hrs." by NP #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 2000, 2400, 0400 vital signs were not documented by CNA #1, or RN #2.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) had documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at the time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

3. Closed medical record review of Patient #13, a 76 -year-old female admitted on 02/01/2021 for complicated diverticulitis (small bulging pouches develop in the digestive tract), septic shock, (widespread infection causing organ failure) and respiratory failure (your blood does not have enough oxygen). Review of the Admission Orders dated 02/01/2021 at 1630 revealed "Vital Signs q 4 hrs.", by NP #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 2000, 2400 and 0400 vitals were not documented by CNA #1, or RN #3.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that is was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

4. Closed medical record review of Patient #14, a 51-year-old male admitted on 02/17/2021 for acute hypoxic respiratory failure. Review of the Admission Orders dated 02/17/2021 at 1500 revealed "Vital Signs: q 4 hrs.", by Certified-Physician Assistant (C-PA) #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 2000, 2400, and 0400 vital signs were not documented by CNA #1, or Licensed Practical Nurse (LPN) #4.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) had documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

5. Closed medical record review of Patient #15, a 31-year-old female admitted on 12/04/2020 for AMS (altered mental status). Review of the Admission Orders dated 12/04/2020 at 1630 revealed "Vital Signs: q 4 hrs.", by NP #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 2000, 2400, and 0400 vital signs were not documented by CNA #1, or LPN #4.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) had documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

6. Closed medical record review of Patient #16, a 67-year-old male admitted on 02/15/2021 for acute on chronic hypoxic respiratory failure. Review of the Admission Orders dated 02/15/2021 at 1630 revealed "Vital Signs: q 4 hrs." by NP #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 2000, 2400, and 0400 vital signs were not documented by CNA #1, or LPN #4.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

7. Closed medical record review of Patient #17, a 73-year-old male admitted on 02/27/2021 for acute hypoxic respiratory failure from history of Covid (acute viral respiratory illness), pleural effusion (fluid around the lung), and pulmonary hypertension (A type of blood pressure that affects the arteries in the lungs). Review of the Admission Orders dated 02/27/2021 at 1241 revealed "Vital Signs: q 4 hrs." by NP #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 2000, 2400 and 0400 vital signs were not documented by CNA #1 or LPN #4.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) had documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

8. Closed medical record review of Patient #18, a 66-year-old male admitted on 02/08/2021 for acute hypoxic respiratory failure secondary to Covid-19. Review of the Admission Orders dated 02/08/2021 at 1630 revealed "Vital Signs: q 4 hrs." by C-PA #1. Review of the daily Intake/Output Flow Sheet dated 02/28/2021 revealed 0400 vital signs were not documented by CNA #1 or RN #1.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) had documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

9. Closed medical record review of Patient #19, an 81-year-old female admitted on 02/22/2021 for acute hypoxic respiratory failure secondary to Covid-19. Review of the Physician Admission Orders dated 02/22/2021 at 1330 revealed "Vital Signs: q 4 hrs." by C-PA #1. Review of the Daily Intake/Output Flow Sheet dated 02/28/2021 revealed 2000, 2400 and 0400 vital signs were not documented by CNA #1 or RN #2.

CNA #1 was not available for interview.

Interview on 04/21/2021 at 1720 with Chief Nursing Officer #1 revealed that in her investigation, CNA #1 did do the vital signs, she did not document them. Interview revealed that the CNA's used a spreadsheet, and copy them for the nurse at 2000, 2400 and 0400 each shift for review. Interview revealed that it was the CNA's responsibility to document the vital signs, but also the RN's to follow up and ensure they are done and documented. Interview revealed that the hospital policy was not followed.

Telephone interview on 4/22/2021 at 1030 with Charge Nurse, RN #2 revealed, that she worked 1900-0700 on 02/28/2021 "I assumed she (CNA #1) had documented the vital signs...We are supposed to check that all documentation is completed. Documentation should be done at time the vital signs were completed. The RN is responsible to check behind the CNA. They report to us."

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