HospitalInspections.org

Based on document review and interview, nursing services failed to document in the medical record (MR) the discontinuation of intravenous (IV) access on 3 of 10 patient medical records reviewed (P2, P4, and P5).

Findings include:

1. Facility procedure titled, Skills: Intravenous Therapy: Discontinuation-CE/NCPD, published April 2023, indicated on page 2, 26. Document the procedure in the patient's record.

2. Review of P2's MR indicated IV placed on 2/4/24 at 1:32 am to the right forearm. P2 DC'd (discharged) from facility on 2/8/24. MR lacked documentation of IV site discontinuation.

3. Review of P4's MR indicated IV placed on 3/3/24 at 2:33 pm to the right brachial. P4 DC'd from facility on 3/7/24. MR lacked documentation of IV site discontinuation.

4. Review of P5's MR indicated port a cath to right chest accessed on 2/25/24 at 7:00 am and de-accessed by P5 on 2/29/25 at 1:00 am. MR indicated port a cath re-accessed on 2/29/24 at 2:00 am. P5 DC'd from facility on 3/2/24. MR lacked documentation of port a cath de-access.

5. In interview, on 4/3/24 at approximately 3:00 pm, A5 (Clinical Informatics) verified P2, P4, and P5 did not have discontinuation of IV access documented prior to DC (discharge) from facility. A5 verified P2, P4, and P5 did not require IV access for arranged medical care after discharge from facility.

6. In interview, on 4/3/24 at approximately 6:10 pm, A1 (Accreditation and Regulatory Office) verified the document provided, titled Skills: Intravenous Therapy: Discontinuation-CE/NCPD, was a facility policy.