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Based on medical record review, hospital contract review and staff interview, the hospital failed to ensure that the contract between the hospital and the IV (Intravenous)provider service defined a time line for response to "STAT (latin word for immediately)" medical orders.

Findings include:

The 1/13/10 review of the hospital's contracted IV service agreement reflects: "Wisconsin Vascular Access Service, LLC and Aurora Health Care Metro, INC" reflects under "Article 2-Responsibilities of WVAS (Wisconsin Vascular Access Service)...2.1.3 Scheduling. WVAS shall provide PICC (Peripherally Inserted Central Catheter) Line Services and IV Therapy Services pursuant to an order between the hours of 8:00 a.m. to 8 p.m. Monday through Saturday. WVAS shall provide on-call services during all other times and on all other days. WVAS shall provide timely placement of PICC line services, with a goal of placement of an appropriate means of vascular access within an average of four (4) hours from placement of an order to completion of the service. For PICC Line insertions only, service will be provided within four (4) hours of a request, unless the circumstances indicate a more immediate response time."

The 1/13/10 medical record review of Patient #1's physician's orders dated 9/27/09 (Sunday) at 5:45 a.m. written by Attending Physician G reflects: "PICC line Now".

The 1/13/10 medical record review reflects that the request was made to WVAS PICC line service on 9/27/09 at 7:55 a.m. for "...PICC Line Placement, Priority *STAT* ".

Continued medical record review on 1/13/10 of the "Invasive Procedures- Pre-procedure Documentation, and the Procedure without Sedation- Physical, Consent, Post procedure note" filed by the contracted PICC Line placement RN H on 9/27/09 for Patient #1 did not have times of the pre-, intra-, or post treatments or services recorded. (Reference A0450, example #2). There was a preprinted physician's order set "Vascular PICC Line Placement orders" dated and timed for 9/27/09 at 12:08 p.m. (4 hours and 13 minutes after the STAT order was initiated).

On 1/13/10 at approximately 2 p.m. interview with Director of WVAS J verified Patient #1's PICC line placement was performed at 12 noon on 9/27/09.

Continued medical record review on 1/13/10 reflects PICC line placement was verified by x-ray after insertion, and the PICC line was "OK to use..." per a physician's order at 1 p.m. (6 hours and 18 minutes after the initial medical order) on 9/27/09.

On 1/21/10 at approximately 10:10 a.m. it was verified by VP (Vice President) RN Executive C and Chief Medical Officer/ Physician I that the contract contained no specific language related to how the contracted service should respond to STAT medical orders for PICC line placement.

Based on medical record review, hospital policy review and staff interviews, the hospital failed to ensure that an RN supervised the care in 1 of 3 sampled patients reviewed (Patient #1), to provide physician- ordered IV (intravenous infusion) treatment and services in a safe and timely manner.

Findings include:

The 1/13/10 review of Hospital "Policy #1007, effective 8/6/07" states on page 5 of 27 under: " II. Peripheral Intravenous (IV) Catheter....A.1. A physician's order is necessary to perform venipuncture, including insertion, capping and discontinuation of catheters...A. 4. Document the venipuncture site, type and gauge of needle or catheter in the patient record...". On page 6 of 27, under "II. C. Unsuccessful Peripheral Intravenous Insertion Attempts" it states: "It is recommended that no more than two IV insertions be attempted, the nurse will contact a resource to insert IV. After four unsuccessful IV sticks, consider alternative IV access with appropriate agency resources (e.g., anesthesia, CRNA, etc.) If no vascular access obtained notify attending physician."

The 1/13/2010 and 1/14/2010 medical record review of Patient #1 reflects the following:
On 9/26/09 at 10:09 a.m., Patient #1 an 88 year old female was brought to the ED (Emergency Department) after a fall in the nursing home. The ED record and ED report # 4203369 documented that on 9/26/09 at 11:15 a.m. Patient #1 was medically screened in the ED, and diagnosed with Right Hip Fracture requiring orthopedic surgical evaluation and Chronic Anemia (9/26/09 at 12:30 p.m. hemoglobin was 8.4, with normal being 12-15 g/dL).

The ED IV (intravenous) administration record dated 9/26/09 states at 11:55 a.m., RN A inserted a 20 gauge IV needle in Patient #1's right antecubital space (inner elbow) which was capped (special hub attached to IV needle to keep vein open without instilling continuous drip fluids) for future use per ED physician's order. After insertion , ED RN A documented no further evaluation of the IV site during the ED stay or discharge.

The patient was admitted to the hospital for orthopedic evaluation and treatment and transferred by the hospital transport services to a orthopedic nursing care unit.

Patient #1 was assigned to RN B who completed an initial nursing assessment at 4:18 p.m. on 9/26/09, and documented "no" when computerized documentation asked if "Patient on IV". Review of this assessment reflects no documentation/verification of the right antecubital space IV being intact/patent. There is no documentation that RN B attempted to find out what happened to the IV inserted in the ED.

At 9/26/09 at 5:05 p.m. the following medical telephone orders were received by RN B from Orthopedic Surgeon E: "Plan for OR (operating room) tomorrow, Transfuse 2 units PRBCs (packed red blood cells)...". Review of the medical record reflects there is no documented evidence that RN B informed the orthopedic surgeon about the status of the IV. During RN B's care on 9/26/09 (unit admission to 7 p.m.), there was no documentation that RN B attempted to insert a new IV for Patient #1, even though Patient #1 had an ED physician's order for a "capped IV line" .

The 1/14/10 review of the physician's orders reflects at 9:45 p.m. on 9/26/09, RN F documents the following medical telephone orders by Attending Hospital Physician G: "PICC (Peripherally Inserted Central Catheter) line in AM (9/27/09) -unable to obtain peripheral IV access." There is no documented evidence that RN F informed Orthopedic Surgeon E, who ordered the blood transfusion, about the status of the IV, or attempted to insert an IV, or followed hospital policy to access "other resources" before telephoning the Attending Physician G to receive the order to delay the start of an IV until the AM (9/27/09).

Interview with Vice President RN Executive C on 1/21/10 at approximately 10:10 a.m. stated that under Hospital Nursing Policy #1007, the resource contact for the nurse after two unsuccessful attempts would be " the SuperUsers (RN specially trained in ultrasound guided IV insertion), the contracted Wisconsin Vascular Access Service (WVAS) PICC (peripherally inserted central catheters) team, or Interventional Radiology (physician-inserted central IV lines). When asked about the lack of documentation regarding the "missing IV", Vice President RN Executive C stated that this hospital "has not historically required nursing staffs to document failed IV attempts", therefore "there would not be any documentation ". Vice President RN Executive C could not define, when asked, how the above hospital policy was evaluated to ensure that limited IV attempts and utilization of resources were accomplished if no documentation was required.

Interview with ED RN A on 1/13/10 at 2:30 p.m. reflects that "If the IV was not intact on discharge from ED, problems would have been documented."

RN B responded to request for telephone interview by leaving a voice mail message on 1/28/10 at 2:21 p.m., stating that she remembered attempting at least once to start an IV for Patient #1, and stated that the hospital did not require documentation of failed IV attempts.

RN F was interviewed by phone on 1/26/10 at 2:34 p.m., and stated she could not remember the event but felt that if the doctor was called that she would have attempted to start an IV on Patient #1. RN F stated that she was able to recover an assignment sheet showing the RN B reported a need for Patient #1 to have an IV started.

RN B and RN F did not say or document why they did not attempt to contact the "other resources" as per nursing policy #1007.

Patient #1 had a laboratory blood draw on 9/27/09 at 4:40 a.m. showing a decrease in hemoglobin to 7.5 g/dL.

The 1/13/10 medical record review of Patient #1's physician's orders dated 9/27/09 (Sunday) at 5:45 a.m. written by Attending Physician G reflects: "PICC line Now, Transfuse 1 unit PCM (packed blood cells) at 100 cc/hour, then Lasix 20 mg. then transfuse other unit of PCM, Dextrose .45% at 90 cc/hour, nothing by mouth... No IV access for 12-15 hours and patient is in the hospital. Totally uncalled for and unsafe."

Interview with Attending Physician G on 1/14/10 at 8:30 a.m. reflects that on arrival to the orthopedic unit at 5:45 a.m. on 9/27/09, he felt Patient #1 was cardiovascularly stable. The Attending physician stated he was told that the patient was eating and drinking without difficultly. Attending Physician G stated in this that he felt no harm was caused to Patient #1 due to the delay in IV delivery. Attending Physician G stated that the IV orders he wrote at 5:45 a.m. on 9/27/09 were medically necessary treatments.

The 1/13/09 medical record review reflects that the request was made to WVAS PICC line service on 9/27/09 at 7:55 a.m. for "...PICC Line Placement, Priority *STAT* ".
There was a 2 hour and 5 minute delay in the medical order being written by the physician and the order being sent to the WVAS service. It could not be determined what caused the delay in the ordering of the medical treatment.

On 1/21/10 at approximately 10:10 a.m. it was verified by VP RN Executive C and Accreditation Director D that the medical record contained no documentation or informative evidence that the nursing staff supervised and evaluated the intravenous care after inserting an medically-ordered IV in the ED. It was verified that there was no documentation or informative evidence of what happened to the IV that was started in the ED. It was verified that there was no documentation or informative evidence that the nursing staff followed nursing policy #1007 in an attempt to secure IV access before calling Attending Physician G to delay medically ordered treatment.

The time delay with the "STAT" medical order and the transmittal of the order by nursing staff to the WVAS service was verified by VP RN Executive C and Accreditation Director D when viewing the physician's order sheet on 9/27/09 at 5:45 a.m. on 1/21/10 at approximately 10:10 a.m. It was verified that there was no informative evidence of why there was a delay in the medical order being sent to the PICC line service.

Based on medical record review, hospital policy review, intravenous standards of practice review and staff interviews, the hospital failed to ensure that 1 of 3 sampled patient medical records (Patient #1) contained documentation defining the course and results of care, treatment, and services provided by the hospital; and that 1 of 3 sampled patient records (Patient #1) documented a time line of events for intravenous services and treatments.

Findings include:

1) Patient #1 had a peripheral IV (needle inserted in right arm for intravenous fluids) inserted in the ED (Emergency Department), on transfer to the medical unit this IV was missing. There was no documentation of IV discontinue or attempts to restart IV by the responsible nursing staffs on 9/26/09. (Reference A0395)

The 1/13/10 review of Hospital "Policy #1007, effective 8/6/07" states on page 5 of 27 under: " II. Peripheral Intravenous (IV) Catheter....A.1. A physician's order is necessary to perform venipuncture, including insertion, capping and discontinuation of catheters...A. 4. Document the venipuncture site, type and gauge of needle or catheter in the patient record...".

Interview with Vice President RN Executive C on 1/21/09 at approximately 10:10 a.m. stated that this hospital "has not historically required nursing staffs to document failed IV attempts", and could not define how the above hospital policy was evaluated if that documentation was not required.

According to the "Intravenous Nurses Society: Intravenous Nursing Standards of Practice, Journal of Intravenous Nursing. 23 (Suppl, 63) November/December 2000"
documentation should include:
"Type, length and gauge of the catheter inserted,
Date and time of the insertion,
Number / location of attempts,
Name of the vein,
Type of dressing applied to the site,
How the patient tolerated the procedure,
Name of the person inserting the device."

The 1/13/2010 and 1/14/2010 medical record review of Patient #1 reflects the following:
The ED IV (intravenous) administration record dated 9/26/09 states at 11:55 a.m. RN A inserted a 20 gauge IV needle in Patient #1's right antecubital space (inner elbow) which was capped (special hub attached to IV needle to keep vein open without instilling continuous drip fluids) for future use.

Patient #1 was transferred by the hospital transport services to a orthopedic nursing care unit.

Patient #1 was assigned to RN B who completed an initial nursing assessment at 4:18 p.m. on 9/26/09, and documented "no" when asked if "Patient on IV". Review of this assessment reflects no documentation/verification of the right antecubital space IV being intact/patent. There is no documentation that RN B attempted to find out what happen to the ED- inserted IV.

On 9/26/09 at 9:45 p.m., RN F documents telephone orders by Attending Hospital Physician G: "PICC (Peripherally Inserted Central Catheter) line in AM (9/27/09) -unable to obtain peripheral IV access."

Complete review of the medical record reflects no documented evidence of the course of IV therapy and results of that care between the start of the IV in the ED and the Call to the Attending Physician G.

On 1/21/10 at approximately 10:10 a.m. it was verified by VP RN Executive C and Accreditation Director D that the medical record contained no documentation of what happened to the IV that was inserted in the ED, and that it could provide no documented evidence that RN B and RN F attempted IV access for Patient, other that the medical order written by RN F. They also verified that their were no incident /accident reports filed for Patient #1 during the hospital stay. The details of Patient #1's IV therapy care and services were not completely documented in order to evaluate the course of treatment on 9/26/09.


2) The 1/13/10 review of the hospital's contracted IV service agreement reflects: "Wisconsin Vascular Access Service, LLC and Aurora Health Care Metro, INC" reflects under "Article 2-Responsibilities of WVAS (Wisconsin Vascular Access Service)...2.4 Patient Visit Documentation. WVAS shall comply with Hospital and Payor documentation requirements, submitting all documentation related to the Services performed hereunder within the Hospital defined medical record completion timeframe".

Patient #1's medical record review on 1/13/10 of the "Invasive Procedures- Pre-procedure Documentation, and the Procedure without Sedation- Physical, Consent, Post procedure note" filed by the contracted PICC Line placement RN H on 9/27/09, reflects that there are no times documented for the following procedural services and treatments provided by RN H:
No time documentation of when the pre-procedure checklist was completed (identification of patient, verification of written order, insertion site verification).
No time documentation of when the procedure checklist was completed (hard copy of written order obtained and read aloud in procedure room, "timeout" verification).
No time documentation of when the post-procedure assessment note was completed.
There was no time documentation noted when Patient #1 made a mark verifying informed consent.

On 1/21/10 at approximately 10:10 a.m. the lack of timeline documentation was verified by VP RN Executive C. VP RN Executive C verified that hospital policy was that all medical record entries be timed, dated and authenticated.