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Based on observation, interview, and hospital policy review, the hospital failed to follow their policy in relation to capping intravenous (IV) tubing for 1 of 19 intravenous tubings observed (Tubing in Room 519A).

The finding includes:

On March 29, 2017 at 10:05 AM, during a tour of the Grant 5 unit with the Nurse Manager, the surveyor observed an IV tubing draped over the IV pole in Room 512A. At the end of the IV tubing, a white cap was attached. The Nurse Manager, who observed the white cap at the same time as the surveyor, indicated that the white cap at the end of the IV tubing was not considered sterile and the protocol was to use a green or red alcohol impregnated cap to cover IV tubing at the connection site.

A review of the hospital's policy (25.003 IV Policy for Peripheral and Midline) indicated, on page seven, that the tubing would be capped with a sterile dead end cap when IV therapy was disconnected from the patient.

The use of the white cap, which was not sterile, instead of the approved sterile green or red alcohol impregnated cap, caused the potential for an infection.

This finding was confirmed with the Nurse Manager at the time of the observation.

Based on record reviews and interviews, it was determined the hospital failed to ensure patient care was accurately and completely documented for 3 of 10 records reviewed (Records A, G, and J).

The findings include:

1. Record A indicated that the patient's nursing care plans, dated February 12, 2017, February 17, 2017, February 22, 2017, February 28, 2017, March 5, 2017, and March 8, 2017, indicated that, as a nursing intervention, the patient would be turned every two hours. A review of the nursing intervention graphic, which was a timeline of interventions provided to the patient, and the nursing progress notes failed to show documentation that the patient was turned every two hours as indicated in the patient's nursing care plan.

2. Record G indicated that patient's nursing care plans, dated February 24, 2017 and February 28, 2017, indicated that, as a nursing intervention, the patient would be turned every two hours and a head to toe skin assessment would be done, at a minimum, every shift. A review of the nursing intervention graphic, which was a timeline of interventions provided to the patient, and the nursing progress notes failed to show documentation that the patient was turned every two hours or that a head to toe evaluation was performed every shift as indicated in the patient's nursing care plan.

3. Record K indicated that patient's nursing care plans, dated February 20, 2017, February 22, 2017, and February 24, 2017, indicated that, as a nursing intervention, the patient would be turned every two hours and a head to toe skin assessment would be done, at a minimum, every shift. A review of the nursing intervention graphic, which was a timeline of interventions provided to the patient, and the nursing progress notes failed to show documentation that the patient was turned every two hours or that a head to toe evaluation was performed every shift as indicated in the patient's nursing care plan.


On March 30, 2017 between approximately 10:30 AM and 11:30 AM, the surveyor conducted the above record reviews with the Director of Nursing Systems. She verified that the above three patient records failed to have evidence of documentation that the nursing care plans were implemented as written.

On March 30, 2017 at approximately 2:00 PM, the surveyor conducted an additional record review of Records A, G, and K with the Nurse Manager of the Grant 5 nursing unit. She also verified that the above three patient records failed to have evidence of documentation that the nursing care plans were implemented as written.