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Based on review of records, facility policies and procedures and interviews with facility staff, the facility failed to assure that the patient received care in a safe setting as 1 of 1 patients sustained injury to her left arm from an intravenous line infiltrating during a visit to the emergency department in violation of facility policies.

The findings were:
Review of the medical record of patient #1 reflected an entry by personnel #1that on 5/19/11 22:41 "Integumentary: IV (intravenous) to L (left) arm infiltrated. Pt (patient) has water blisters around elbow & on top of arm midway between shoulder and wrist. IV dc'ed (discontinued), arm wrapped with non-adhesive telfa & blankets from warmer applied to reduce swelling." The record also reflected that the patient had been administered "IV morphine 4 mg initiated at 5/19/11 22:10 ...Zofran 4mg initiated at 5/19/11 22:10." A complaint submitted to the facility by patient #1 reflected that she had complained to the nurse several times about the IV burning prior to when the medications were administered. There was no indication in the medical record of patient #1 that the nurse (personnel #1) notified the physician of the IV infiltration or the water blisters around the patients left elbow and on top of her arm. There were no physician orders in the medical record of patient #1 for dressings or warm blankets to be applied to the left arm.

The facility policy entitled "Intravenous Push Medications", policy #N37 with a revision date of 4/98, reflected that "Procedure F. Ensure IV is infusing properly." The facility policy entitled "Guidelines for Infection Control in Intravenous Therapy", policy #2.103 with an effective date of 8/03 reflected that "Peripheral venous catheter sites that are phlebitic, or infiltrated should be discontinued and/or changed immediately."

The facility policy entitled "Notifying Physician of Changes in Patient Condition", policy H5 with an effective date of 11/98 reflected that "The nurse responsible for care of the patient will notify the physician whenever the assessment of a patient's condition shows a significant deterioration or change ..." The facility policy entitled "Incident Reporting", policy #10.004 with an effective date of 4/99 reflected that "M. Incident Report forms should be utilized in the following circumstances/incidents: 1. physical injury of patients ...." The facility policy entitled "Patient Rights and Responsibilities", policy #4.005 with an effective date of 1/97 reflected that "The patient has a right to considerate and respectful care ...."

In an interview with personnel #5 on 11/1/11 at 3:20 PM, she stated that the physician was not notified and there was no incident report completed by the nurse which is normal procedure when a patient sustains an injury in the facility.

Based on review of records, facility policies and procedures and interviews with facility staff, the facility failed to assure that drugs are administered in accordance with accepted standards of practice as intravenous medications were given through an infiltrated intravenous line in 1 of 1 patients in violation of facility policy.

The findings were:
A complaint submitted to the facility by patient #1 reflected that she had complained to the nurse several times about the IV burning prior to when the medications were administered. The medical record of patient #1 reflected that the patient had been administered "IV morphine 4 mg initiated at 5/19/11 22:10 ...Zofran 4mg initiated at 5/19/11 22:10." The medical record of patient #1 reflected that on 5/19/11 22:41 "Integumentary: IV (intravenous) to L (left) arm infiltrated. Pt has water blisters around elbow & on top of arm midway between shoulder and wrist."

The facility policy entitled "Intravenous Push Medications", policy #N37 with a revision date of 4/98, reflected that "Procedure F. Ensure IV is infusing properly." The facility policy entitled "Guidelines for Infection Control in Intravenous Therapy", policy #2.103 with an effective date of 8/03 reflected that "Peripheral venous catheter sites that are phlebitic, or infiltrated should be discontinued and/or changed immediately."

In an interview with personnel #5 on 11/1/11 at 3:20 PM, in response to a question about the usual procedure for intravenous medications, she stated that the nurse should check the IV for patency, and if there was any indication that the IV was not patent, to stop the medication administration and notify the physician.

Based on review of records, facility policies and procedures and interviews with facility staff, the facility failed to assure that drugs are administered in accordance with accepted standards of practice as intravenous medications were given through an infiltrated intravenous line in 1 of 1 patients in violation of facility policy.

The findings were:
A complaint submitted to the facility by patient #1 reflected that she had complained to the nurse several times about the IV burning prior to when the medications were administered. The medical record of patient #1 reflected that the patient had been administered "IV morphine 4 mg initiated at 5/19/11 22:10 ...Zofran 4mg initiated at 5/19/11 22:10." The medical record of patient #1 reflected that on 5/19/11 22:41 "Integumentary: IV (intravenous) to L (left) arm infiltrated. Pt has water blisters around elbow & on top of arm midway between shoulder and wrist."

The facility policy entitled "Intravenous Push Medications", policy #N37 with a revision date of 4/98, reflected that "Procedure F. Ensure IV is infusing properly." The facility policy entitled "Guidelines for Infection Control in Intravenous Therapy", policy #2.103 with an effective date of 8/03 reflected that "Peripheral venous catheter sites that are phlebitic, or infiltrated should be discontinued and/or changed immediately."

In an interview with personnel #5 on 11/1/11 at 3:20 PM, in response to a question about the usual procedure for intravenous medications, she stated that the nurse should check the IV for patency, and if there was any indication that the IV was not patent, to stop the medication administration and notify the physician.