HospitalInspections.org

Based on interview and record review the hospital failed to ensure 5 of 5 patients (Patient #1, #12, #3, #4, and #6) received medical care in a safe setting and that follow-up assessments of elevated and/or decreased blood pressures were completed.

Findings included:

1) Patient #1's discharge summary dictated 02/26/13 reflected an admission date of 01/31/13. The patient was discharged on 02/09/13 and transferred to a medical hospital emergency department "...for hypotension [low blood pressure], syncope [fainting], and acute renal failure." Final diagnoses included Dementia With Delusions and Depression, Hypertension, Coronary Artery Disease with Pacemaker, Renal Insufficiency, Chronic Back Pain and Left Scapula Pain, History of Rectal Hemorrhage, Gastroesophageal Reflux Disease, and Hypercholesterolemia.

The history and physical examination document dated 02/01/13 at 12:00 PM reflected Patient #1 had heart arrhythmias (irregular heart rate), a pace maker, Coronary Artery Disease, Gastric Reflux, high blood pressure.

Physician Orders dated 01/31/13 at 23:00 reflected diagnoses including Pacemaker In Situ, GERD, Atrial Fibrillation, Sick Sinus Syndrome, Pedal Edema, Hypertension, Rectal and Anal Hemorrhage, and Coronary Artery Disease.

Physician Orders dated 02/03/13 at 13:30 reflected an order for a medical consult to evaluate Patient #1's blood pressure of 180/89.

The admission nursing assessment dated 01/31/13 reflected Patient #1 had a history of cardiac disease and hypertension.

The 02/03/13 patient assessment sheet reflected "08:00 AM BP (blood pressure) 180/89...15:00 BP 179/88." No documentation was found indicating Patient #1 was reassessed.

The 02/04/13 patient assessment noted a blood pressure of 165/82 at 08:00 AM. A second reading, untimed, noted Patient #1 had a blood pressure of 84/53. There is no evidence of a re-measurement of Patient #1's low blood pressure.

The 02/06/13 patient assessment documentation reflected Patient #1's blood pressure of 144/77 at 16:00. There is no evidence Patient #1's blood pressure was reassessed.

The 02/09/13 patient assessment recorded "08:00 AM BP 84/47." Multidisciplinary progress notes dated 02/09/13 at 08:55 AM reflected while in the day area, Patient became "unresponsive...drooling" with "shallow respirations." Staff was "unable to palpate radial pulse...and get blood pressure..." Patient #1 was transferred to a medical hospital by emergency services and was ...admitted for hypotension, syncope..."

Hospital Personnel #4 acknowledged on 05/10/13 around 17:20 that Patient #1's fluctuating blood pressure was not followed up and stated reassessments were left to the individual nurse's judgement.

2) Patient #12's history and physical document reflected the patient had a medical history of CVA and Hypertension. Her diagnoses included Cardiovascular Disease with a history of CVA with Residual Deficits 05/08/13 Patient #12 had a blood pressure of 172/100 at 08:00 AM. Her blood pressure was remeasured eight hours later at 18:04 and was 161/91. There is no further documentation of additional blood pressure readings.

Hospital Personnel #13 was observed with a vital sign board on the geriatric unit on 05/10/13 at 15:55. Hospital Personnel #13 stated she took patients' vital signs and reported them to the nurse but did not retake high or low blood pressures unless instructed to do so.

Hospital Personnel #14 stated on 05/10/13 at 16:01 she had rechecked Patient #12's blood pressure on 05/08/13 "but did not write it down."

3) Patient #3 was admitted on 02/04/13 and discharged on 02/25/13 with diagnoses including Late Dementia of Alzheimer's Type With Behavioral Disturbance.

Patient assessment records reflected Patient #3's blood pressure of 87/58 on 02/03/13 at 16:00. His blood pressure was measured to be 82/55 on 02/05/13 at 20:15 and 73/53 on 02/23/13 at 15:00. There is no documentation of follow up blood pressure readings.

4) Patient #4 was admitted on 02/07/13 and discharged on 03/01/13 with final diagnoses including Very Recent Cerebrovascular Accident and Hypertension. On 02/10/13 Patient #4's blood pressure reading was 183/75 at 15:00. There is no further documentation of a follow-up blood pressure.

5) Patient #6 was admitted on 02/13/13 with a history of stroke. The patient was discharged on 02/18/13 with final diagnoses including Hypertension, Cerebrovascular Accident/Transient ischemic Attacks. Patient #6's blood pressure of 152/71 was not reevaluated on 02/05/13 at 16:00.

The Hospital's Nursing Policy Assessment and Reassessment of Patients dated 03/2011 reflected the expectation that the "Registered Nurse will assess each patient at a minimum every 8 hours and more often as deemed necessary."

Nursing Policy:Rapid Response Team dated 03/2011 reflected "early warning signs to look for in patients including acute changes in systolic blood pressure less than 90 mmHg."

The Hospital Patient Rights and Responsibility Policy dated 01/2013 reflected "without limitation patients shall be entitled to...medical care and treatment in accordance with the highest standards accepted in medical practice ..."

The American Heart Association (2013) warned that "When BP readings rise to 180 or above for the systolic...number OR 110 or above for the diastolic...number, call for emergency medical treatment immediately" and stated that "77% of Americans treated for a first stroke and 69% of Americans who have a first heart attack have blood pressure over 140/90" (http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/WhyBloodPressureMatters/Why-Blood-Pressure-Matters_UCM_002051_Article.jsp).