HospitalInspections.org

Based on staff interview, personnel file review, and policy and procedure review, the facility failed to ensure annual skills competency was documented and maintained in two (2) of three (3) personnel files reviewed; Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1.

Findings Include:

During interview on 01/19/2022 at 11:40 a.m., the Director of Quality, Risk and Complaints confirmed there was no documented evidence in LPN #1 and RN #1's personnel files, of annual skills competency checklists from 01/01/2021 to 12/31/2021.

Personnel file review for LPN #1 and RN #1 revealed no documented evidence of annual intravenous (IV) skills competency for the period reviewed 01/01/2021 through 12/31/2021.

Review of the facility's "Nursing Competency Assessment" policy, NURS 0062, reviewed 06/2020, revealed: " ...Ongoing Assessments are performed annually and as needed. Ongoing assessment is conducted and documented through a process that considers ...annual performance review process ...".

During exit conference on 01/19/2022 at 1:55 p.m. survey findings were discussed and no further documentation was submitted for review.

Based on staff interview, medical record review and policy and procedure review, the facility failed to ensure a complete and accurately documented medical record was maintained for one (1) of three (3) medical records reviewed; Patient #2.

Findings Include:

During an interview on 01/18/2022 at 4:45 p.m. Registered Nurse (RN) #1 confirmed the intravenous (IV) line in Patient #2's left forearm had been stopped (IV fluids paused) by Licensed Practical Nurse (LPN) #1 on 11/28/2021. RN #1 further confirmed that she could not remember if she restarted the IV in Patient #2's right hand but confirmed if she had restarted the IV in Patient #2's right hand she would have documented this in Patient #2's medical record.

During an interview on 01/19/2022 at 11:45 a.m., LPN #1 confirmed on 11/28/21 she flushed the IV line in Patient #2's left forearm with normal saline and Patient #2 complained of pain. She further confirmed the IV site was patent (intact) but could not remember the name of the nurse she reported Patient #2's complaints of IV pain too on 11/28/2021. She confirmed she did not remove Patient #2's IV line from the left forearm or restart Patient #2's IV line on 11/28/2021.

During interview on 01/19/2021 at 11:40 a.m., the Director of Quality, Risk and Complaints confirmed there was no documented evidence in Patient #2's medical record of when the staff removed Patient #2's IV from the left forearm and restarted Patient #2's IV in the right hand on 11/28/2021.

Medical record review for Patient #2 revealed: " ...Progress Notes ...dated 11/28/2021 ...LPN #1 documented at 15:56 (3:56 p.m.) P/A (Patient Assessment)-RN LPN Hourly Rounds-Nurses Note: ...INT (intravenous line) to left FA (forearm) ...RN #2 documented at 19:35 (7:35 p.m.) P/A-Nursing Physical Assessment ...IV Site Assessment: Patent, Clear, No redness at site, No edema at site-IV Site: Right, Hand ...IV Interventions: Site unremarkable ...". Further medical record review revealed no documented evidence on 11/28/2021 from 3:56 p.m. to 7:35 p.m. of the staff member that removed Patient #2's IV site from the left forearm and restarted Patient #2's IV site in the right hand.

Review of the facility's "Nursing Documentation" policy, NURS 0183, revealed: " ...Medical record documentation will be pertinent, concise, timely, and available to all personnel providing care ...Documentation during the shift shall include: any procedure performed for the patient including observation, patient response and outcome ...".

Review of the facility's "IV Therapy" policy, NURS 0147, revealed: " ...Site assessments: To be documented every shift or more often as indicated ...".

During exit conference on 01/19/2022 at 1:50 p.m., survey findings were discussed and no further documentation was submitted for review.