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Based on record review and interviews, the facility failed to meet the requirement because a registered nurse did not ensure physician orders for vital signs were implemented as ordered for the patient of concern.

Findings Include:

a. Review of the medical record on 02/28/18 at 10:00 a.m. in the conference room for the 13 year-old patient of concern revealed the following:

A team progress note on 11/06/17 at 9:23 stated in part, "Patient stated that she cheeked her meds from last night and took them with her morning meds. No evidence to support claim. Vital signs were taken every fifteen minutes for one hour. All were within normal limits."

Vital sign records documented vital signs that included respirations, pulse, and blood pressure taken at 09:00, 09:15, 9:25, 9:30 and 09:45.

A psych evaluation on 11/06/17 at 11:45 stated in part, "Pt states that she cheeked some of meds and that she save them and that she took them in order to hurt herself. Pt states she feels tired this am." The treatment plan included in part, "Monitor VS."

A registered nurse took a verbal order from the patient's psychiatrist on 11/06/18 at 11:00 for "Vital Signs q 15 min x 4, then Q 30 min x 4, then Q 1º x 4 then routine."

There were no vital signs documented every 15 minutes x 4 after 11:00 when the order was taken. The first set of vital signs documented in the medical record after the physician order at 11:00 was not until 13:30 which was 2.5 hours after the physician order. This set of vital signs did not include respirations.

Vital signs were not documented every 30 minutes x 4 as ordered by the physician. The vital signs documented at 13:30 were followed by only two sets of vital signs which were taken at 14:00 and 14:30. This set of vital signs did not include respirations.

Vital signs were not documented hourly x 4 as ordered. There were no vital signs documented between 14:30 and 19:11 which was over 4.5 hours later.

b. The patient's psychiatrist was interviewed on 02/28/18 at 9:23 a.m. in the physician office on the child adolescent unit. The psychiatrist was asked if she would expect the nurse to take the vital signs as ordered. The psychiatrist responded, "You should try to get as close as possible to the order."

c. In an interview on 02/28/18 at 10:07 a.m. in the conference room, S#2 confirmed that the nursing staff did not take the vital signs as ordered by the physician and stated, "The vital signs were done way before the order was written at 11:00 and then they fell off. Hourly vital signs were not taken."

d. A document entitled, "Responsibilities of the Charge Nurse," provided by S#2 was reviewed with S#2 on 02/28/18 at 1:15 p.m. in her office and revealed that it stated the following in part:

"The primary responsibility of the charge nurse is to ensure the delivery of safe, therapeutic care for all patients on the unit but ultimately, the charge nurse is responsible for everything that happens or fails to happen on the unit during their shift."

"Ensuring 24 hour chart checks are properly completed and that all orders have been entered in the computer, profiled by pharmacy or carried out by appropriate staff."