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Based on observation, interview, and policy review, the facility failed to ensure a peripheral intravenous (IV) catheter was inserted in a manner that prevented the possibility of cross contamination for one of eight sampled patients (Patient 8). The failure to employ methods such as the use of clean gloves when inserting an IV catheter had the potential to cause a blood stream infection for the patient observed and could affect any of the 500 patients currently inhouse if they had an IV inserted with the same technique failure.

Findings Include:

Review of the facility policy titled "Catheter Peripheral, Intravenous - Insertion, Maintenance and Discontinuation (Adult)," last approved 06/2020, showed multiple steps for insertion of an intravenous catheter. The policy stated that staff were to wash their hands and don (put on) gloves after opening the IV start kit, setting up needed supplies, and preparing the insertion site.

Observation of a peripheral IV insertion for Patient 8 in the Emergency Department (ED) on 01/08/21 at 3:10 PM showed the patient reclining on a gurney. Staff N, Registered Nurse (RN) was wearing gloves and was retrieving supplies for the procedure. While wearing these gloves, Staff N, RN opened a drawered cart, retrieved supplies from the cart, and then placed them on a Mayo stand (a removable instrument stainless steel tray for instruments or supplies positioned near the procedure site). Wearing the same gloves, Staff N, RN then placed a tourniquet on Patient 8's arm and palpated the skin for veins and removed the tourniquet. Staff N, RN then opened all packaged items on the Mayo stand and flushed (pushed normal saline through) the loop (the catheter extension tubing that attaches to the intravenous catheter). Staff N, RN then went to the cabinet to the right of the gurney, opened the cabinet door and retrieved a towel, which was placed under Patient 8's arm. Still wearing the same gloves, Staff N, RN then reapplied the tourniquet, cleaned the right antecubital (inside the elbow) site with a chlorhexidine swab, allowed the area to dry and inserted a 20-gauge intravenous catheter. Staff N, RN then attached an empty syringe for a blood draw, attached the loop tubing and secured the IV site. Staff N, RN next cleaned the blood from Patient #8's arm and filled the lab tubes with the blood, then removed her gloves and used hand sanitizer.

During an interview on 01/08/21 at 3:18 PM, regarding the failure to change to clean gloves prior to the actual IV insertion, Staff I, ED Nurse Manager (NM) stated that a peripheral IV was a clean procedure not a sterile procedure, and the RN should have minimized touches. Staff I, NM continued by stating that the best practice would be not to touch anything prior to the IV start.