117.41 Emergency patient care
(a) Emergency patient care shall be
guided by written policies and
procedures which delineate the proper
administrative and medical procedures
and methods to be followed in
providing emergency care. These
policies and procedures shall be clear
and explicit; approved by the medical
staff and hospital governing body;
reviewed annually, revised as
necessary; and dated to indicate the
date of the latest review or revision,
or both.
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Observations:
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure vital signs were completed every 15 minutes on patients in the Emergency Department (ED) for four of six applicable ED medical records reviewed (MR1, MR2, MR4 and MR5).
Findings include:
Review of December 7, 2023, of the facility's "Assessment and Reassessment in the Emergency Department" policy, last approved June 20, 2018, revealed "Purpose - To provide all patients entering the Emergency Department with nursing care based on documented assessment of their needs by Emergency Nurses who possess current, comprehensive knowledge and skills in emergency healthcare. The nursing assessment, planning, interventions, evaluation of changes in the patient's condition, responses to interventions and outcomes of care shall be documented on the patient record. Policy - The Emergency Department (ED) nurses shall initiate accurate and ongoing assessment of physical and psychological needs of patients within the Emergency Department Reassessment of patients will be done on a regular basis to determine the patient's response to treatment; note significant changes in the patient's condition and / or patient's diagnosis ...2. All patients admitted to the Emergency Department will have the following documentation: ... b. Initial vital signs: i. Additional vital signs shall be obtained depending on patient's condition. ii. Critical patients every five (5) to 15 minutes as needed iii. Intermediate every one (1) hour iv. All other patients every two (2) hours or prior to discharge ..."
Review of MR1 on April 3, 2024, revealed this patient presented to the Emergency Department (ED) on January 27, 2024, at 0923 with complaint of shortness of breath, weakness, trouble breathing and was clammy. EMP4 triaged MR1 and assigned this patient an ESI of 4. The ED physician wrote orders instructing nursing staff to obtain vital signs every 2 hours and to monitor MR1's pulse oximetry every hour.
Review of MR1 on April 3, 2024, revealed nursing staff documented the following vital signs on MR1 on January 27, 2024:
At 0931 - Temperature 99.6, Pulse Rate 82, Respiratory Rate 20, Blood Pressure 149/77 and O2 Sat by Pulse Oximetry 90 L
At 1248 - O2 Sat by Pulse Oximetry 91 L
At 1325 - Temperature 97.7, Pulse Rate 67, Respiratory Rate 22, Blood Pressure 98/61 and O2 Sat by Pulse Oximetry 91 L.
MR1 was discharged to home at 1325.
There was no documentation in MR1 indicating nursing staff documented MR1's vital every 2 hours and pulse oximetry every hour as instructed by the ED physician.
Interview with EMP3 at the time of the medical record review confirmed the above findings.
Review of MR2 on April 3, 2024, revealed this patient presented to the ED on January 22, 2024, at 1134 with complaint of angina (a type of chest pain caused by reduced blood flow to the heart), shortness of breath, chest pain, chest tightness and shortness of breath. EMP5 triaged MR2 and assigned this patient an ESI of 3. The ED physician wrote orders instructing nursing staff to obtain vital signs every 2 hours.
Review of MR2 on April 3, 2024, revealed nursing staff documented the following vital signs on MR2 on January 22, 2924:
At 1148 - Temperature 98.5, Pulse Rate 83, Respiratory Rate 18, Blood Pressure 145/83 and O2 Sat by Pulse Oximetry 99 L
At 1454 - Temperature 98.5, Pulse Rate 83, Respiratory Rate 18, Blood Pressure 145/83 and O2 Sat by Pulse Oximetry 99 L
MR2 was discharged to home at 1454.
There was no documentation in MR2 indicating nursing staff documented MR2's vital every 2 hours as instructed by the ED physician.
Interview with EMP3 at the time of the medical record review confirmed the above findings.
Review of MR4 on April 3, 2024, revealed this patient presented to the ED on February 2, 2024, at 1427 with complaint of slurred speech, headache and feeling off balance. EMP7 triaged MR4 and assigned this patient an ESI of 2. The ED physician wrote orders instructing nursing staff to obtain MR4's blood pressure every 15 minutes.
Review of MR4 on April 3, 2024, revealed nursing staff documented the following blood pressure on MR4 on February 2, 2024:
At 1430 - 146/75
At 1445 - 144/71
At 1500 - 159/76
At 1515 - 148/65
At 1545 - 147/69
At 1605 - 121/55
At 1630 - 156/67
At 1700 - 116/79
MR4 was transferred to an outside hospital for further evaluation and treatment on February 5, 2024, at 1715.
There was no documentation in MR4 indicating nursing staff documented MR4's blood pressure every 15 minutes as instructed by the ED physician.
Interview with EMP3 at the time of the medical record review confirmed the above findings.
Review of MR5 on April 3, 2024, revealed this patient presented to the ED on February 11, 2024, at 0049 with complaint of chest pain and shortness of breath. EMP6 triaged MR5 and assigned this patient an ESI of 3. The ED physician wrote orders instructing nursing staff to obtain MR5's blood pressure every 15 minutes.
Review of MR5 on April 3, 2024, revealed nursing staff documented the following blood pressure on MR5 on February 11, 2024:
At 0104 - 116/76
At 0150 - 167/102
At 0154 - 124/85
At 0204 - 114/77
At 0641 - 115/72
MR5 was transferred to an outside hospital for further evaluation and treatment on February 11, 2024, at 0900.
There was no documentation in MR5 indicating nursing staff documented MR5's blood pressure every 15 minutes as instructed by the ED physician.
Interview with EMP3 at the time of the medical record review confirmed the above findings.
Continuing deficiency
December 7, 2023
Cross reference (0147)
101.111 Correction Of Deficiency
Cross reference (1706)
117.12 Procedures
| | Plan of Correction - To be completed: 05/17/2024
1. ED 003-003 Assessment and Reassessment policy will be reviewed and/or revised as necessary.
2. ED staff will be educated regarding ED 003-003 Assessment and Reassessment the Emergency Department with a focus on the monitoring and the completion of vital signs per that policy.
3. A random audit of 10 charts of all patients presenting to the ED will be reviewed each week for a period of 6 weeks to assure 100% compliance with policy and procedure with a focus on the completion of vital signs per policy. Chart review will be done by CNO, ED Nurse Manager and/or designees.
4. Any individual deviating from the process of monitoring vital signs will be reeducated on the process. Reeducation to include review of the policy and procedure. The completion of the reeducation will be documented. A random audit of 3 charts per week for 6 weeks will be done on any individual requiring reeducation of the process. At the end of the 6 weeks a reevaluation will be done.
5. The above will be completed by May 17, 2024. The CEO/CNO and/ or designees will monitor for compliance.
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