HospitalInspections.org

Based on a review of facility documents, medical record review, and interviews, licensed nurses employed by Brownfield Regional Medical Center failed to follow the policies and procedures of the hospital for 1 of 1 patients (#1) by not documenting appropriately for IVs [Intravenous catheters] and only attempting venipuncture twice for lab collection.

Findings include:

A review of facility documents revealed in part:
* Policy titled "Standards of Nursing Care (Revised 1/2024)" - reveals in part:
"Policy: It is the policy of Brownfield Regional Medical Center to abide by the following standards in providing to care to our patients.
A. Standard I. Assessment- The nurse collects client health data.
...2. Pertinent data are collected using appropriate assessment techniques.
...5. Relevant data are documented in a retrievable form.
...D. Standard IV. Planning- The nurse develops a plan of care that prescribes interventions to attain expected outcomes.
...4. The plan is documented.
...E. Standard V. Implementation- The nurse implements the interventions identified in the plan of care.
...3. Interventions are documented.
F. Standard VI. Evaluation- The nurse evaluates the client's progress toward attainment of outcomes.
...2. The client's responses to interventions are documented. 3. The effectiveness of interventions is evaluated... 4. Ongoing assessment data are used to revise diagnosis, outcomes, and the plan of care, as needed. 5. Revisions in diagnosis, outcomes, and the plan of care are documented ..."

* Policy titled, "Medication: Intravenous Therapy (Revised 1/24)" reveals in part "8. At the beginning of each shift, it is the responsibility of the RNs [Registered Nurse] to assess all I.V.'s for patency ... Continued observation of the site with documentation should continue throughout the shift [sic] Every two hours is recommended. 9. Once a shift, or more frequently if indicated, nursing staff must document in the patient's medical record the appearance/condition of the I.V. site.
...11. Initial documentation in EMR [Electronic Medical Record], for initiation of I.V. therapy must include I.V. site, size and type of cannula and number of attempts needed to successfully place."

* Policy titled, "Intravenous Maintenance and Catheter Care (Revised 1/2024)" -reveals in part "PROCEDURE: ...Observe infusion sites closely (Restart IV's as necessary for infiltration or redness and swelling.)
...Intravenous Catheter Care ... PROCEDURE: ...Observe for redness, swelling, or leaking at insertion site, (Discontinue the IV if any of these are noted).
...chart the procedure describing any and all observation made ..."

* Policy titled, "Specimen Collection - (revised 2/2024)" reveals in part " ...Special Considerations ... It is best practice to adhere to a two-attempt limit for venipuncture. If unable to obtain specimens after 2 attempts, notify the nurse and the testing technologist/technician of the failed attempts. The nurse will determine the course of action after consulting with the ordering provider."

A review of Patient #1's medical record reveals patient #1 was admitted to the facility on 7/10/25 at 1:08 PM. There was no documentation for initiation of I.V. therapy, including the I.V. site, size and type of cannula and number of attempts needed to successfully place.

On 7/10/25, Staff #11, RN documents the administration of medications to a R arm IV at 1:30 PM, 2:50 PM, and 5:04 PM. No Physical Assessment, IV Assessment, (including patency, size and type of cannula) or Pain Assessment is documented.

The following nursing notes were documented on 07/11/25:
*12:53 AM - Staff #7, RN documents a 20-gauge Right ( R) Antecubital (AC) IV - "IV patent, site checked, drsg [dressing] secure, Dressing changed per policy ..."
*8:10 AM - Staff #6, RN documents a 20-gauge R AC IV, " No redness or edema at site ..."
*1:59 PM - Staff #6 documents a set of vital signs (V/S), a 22-gauge R hand IV "patent, site checked, drsg secure. No redness or edema at site ..."

Staff #6 documents a R AC IV at 8:10 AM and a R hand IV at 1:59 PM. No documentation exists for removing the R AC IV, starting the R hand IV, IV site, size, and type of cannula, and number of attempts needed to successfully place.

On 7/12/25, there was no Physical Assessment including an IV or Pain Assessment documented.

Patient #1 was discharged on 7/12/25 at 1:13 PM. Throughout Patient #1's admission, nursing staff did not document the IV site per facility policy, including the I.V. site, size and type of cannula, number of attempts needed to successfully place, discontinuation of IV, patency at the beginning of each shift, and continued observation of the site (every two hours is recommended). There was no documentation related to the number of lab draw attempts.

Interviews with staff at the hospital revealed in part:

In an interview on 8/12/25 at 12:30 PM Staff #6, RN Utilization Review (UR) and Discharge Planning stated "I remember the patient [#1]. I gave her 2 units of blood and was in her room for hours. I was giving blood in her right AC and blood was leaking around the IV site during the middle of the 1st unit, so probably 30 minutes into it. I started looking for another IV site. Her left AC site was extremely bruised all around. She [Patient #1] said lab had done that, they tried to stick her about 9 times, her words." Staff #6 reported that she started another IV in patient #1's right hand "with 1 stick" and she had "no problems the rest of the time." Staff #6 reported that she thought the repeated venipuncture attempts happened over night on 7/10 - 7/11 or day of admission on 7/10/25. When asked if she had documented discontinuing one IV and started another, she stated "I'm sure we are supposed to document start and stop but I don't know where because I don't normally work on 5 hall. Generally, when I can't find a spot to chart, I make a narrative note but I was focused on vital signs while giving blood. The new IV was working as it should - no infiltration, no leaking, no pain - it worked perfectly the rest of the time - the entire dayshift."

In an interview on the afternoon of 8/12/25, Staff #7, RN, CN (charge nurse) reported that she was the CN on the night of 7/10/25. Staff #7 reported that she would try twice for an IV, if unsuccessful, she would ask another nurse to try twice, then she would message the doctor.

In an interview on the afternoon of 8/12/25, Staff #8, RN, confirmed that she was the CN on the night of 7/11/25. Staff #8 reported that she does not remember anything about patient #1, her IV sites, or any interactions with family. Staff #8 stated, " ...our lab tech ...is awesome. She tries twice and if she can't get it, then she will tell an RN and ask if they want to try. Lab has a policy - they can only do two attempts. It's usually, 2 or 3 sticks per nurse - but if we're not having any luck, we're not gonna try again. We'll let the doctor know. And if the patient says they don't want us to try again we won't."

In an interview on the morning of 8/13/25, Staff #9, lead phlebotomist reported phlebotomists don't document when labs are drawn, how many attempts it takes, or what body site is used. If a phlebotomist tries twice and are unsuccessful, they will get someone else. She did not remember a patient having 8 or 9 "sticks". Staff #9 stated, "If a phlebotomist has trouble they come get me."

While reviewing the medical record for Patient #1 during interviews on 8/12/25 and 8/13/25 staff #3, DON (Director of Nursing) acknowledged that nurses did not provide adequate documentation of the patient's IV or any interventions performed for her IVs, and reported these issues would be discussed at the next Nurses meeting and new procedures would be put in place to improve Nursing documentation.

Based on a review of facility documents, medical record review, and interviews, blood transfusions were not administered in accordance with facility policies and procedures when nurses failed to use the appropriately sized IV catheter and did not document infusion time or vital signs at the required intervals for 1 of 1 patients (#1).

Findings include:

A review of facility policy titled, "Blood: Administration - Transfusion Therapy (Revised 1/2024)" reveals in part:
" ...Packed Red Blood Cells [PRBCs] ... Infusion time: 1.5 to 2 hours if patient not diagnosed with Heart Failure: not to infuse longer than 4 hours; or as specifically ordered by MD [Medical Doctor]...
Vital Sign Frequency: Full set of VS prior to start (include Temperature, Pulse, Respirations, BP [blood pressure], O2 [Oxygen] saturation), then q15minutes x4 [every 15 minutes times 4], q30minutes until infusion is complete ...
Administration:
...Patient must have a large bore IV catheter of nothing smaller than 20g. A CVL [Central venous line] is preferred."

A review of Staff #6's nursing documentation from patient #1's medical record on 7/11/25 reveals in part:

*1:59 PM - Staff #6 documents a set of V/S, a 22-gauge R hand IV "patent, site checked, drsg secure. No redness or edema at site ... 1st unit of PRBCs transfusion start @ 1359 [1:59 PM]. VS will be monitored for the 1st 15 minutes and hourly thereafter."
*4:45 PM - Staff #6 documents a set of V/S and a "Nurses Notes: transfusion completed with no reaction noted. VS are still WNL [Within Normal Limits] and remain at patients [sic patient's] baseline."
*6:26 PM - Staff #6 documents V/S.
*6:46 PM - Staff #6 - "Nurses Notes: patient's VS with baseline for patient, last unit of PRBC 1/2 in. Patient on phone with family. Denies needs."

After starting the PRBCs at 1:59 PM, Staff #6 only documented two more sets of V/S at 4:45 PM and 6:45 PM. Staff #6 did not follow facility policy, by not documenting V/S at appropriate intervals, not documenting the start and stop time for the 2nd unit, and by using a 22 gauge IV catheter instead of 20 gauge or larger.

In an interview on 8/12/25 at 12:30 PM Staff #6, RN, stated "I remember the patient [#1]. I gave her 2 units of blood and was in her room for hours. I was giving blood in her right AC and blood was leaking around the IV site during the middle of the 1st unit, so probably 30 minutes into it. I started looking for another IV site." Staff #6 reported that she started another IV in patient #1's right hand [per the medical record a 22-gauge].