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Based on interviews and record review the facility failed to develop and implement a physical therapy treatment plan to meet the patient's medical needs in 1 of 10 medical records reviewed.

This failure led to the patient not receiving physical therapy treatments as ordered and created the potential for negative patient outcomes.

FINDINGS:

POLICY

According to Assessment/Re-assessment - Interdisciplinary Patient the initial evaluation for physical therapy may only be performed by a Licensed Physical Therapist. The rehabilitation staff (which includes, physical therapy, occupational therapy, and speech therapy) will evaluate the functional status of any patients referred to one of its disciplines as soon as possible and within 72 hours of notification of referral.

According to Plan for the Delivery of Patient Care, Treatment and Services essential components of the plan include assessing patient needs, planning care, treatment, and services, providing care, treatment, and services, and coordinating care, treatment, and services.

1. The facility failed to provide Physical Therapy as ordered for Patient #1.

a) Review of Patient #1's medical record revealed s/he was admitted to the facility on 09/19/16. Admitting physician orders written on 09/19/16 stated physical therapy should have consulted, evaluated and treated the patient. Patient #1 was discharged from the facility on 10/20/16. Patient #1's medical record revealed no evidence a physical therapist preformed an evaluation or treated Patient #1 during his/her stay at the facility. This was in contrast to physician orders.

b) During an interview on 12/28/16 at 1:20 p.m., Therapist #1 stated there would always be a note present when a patient was seen by a physical therapist.
S/he continued to state even when physical therapy was not initiate the therapist would write an evaluation note that stated therapy was not required.

c) During an interview on 12/28/16 at 11:43 a.m., Therapist #2 stated once a therapy order was received a therapist had 72 hours to complete the initial evaluation. S/he stated if therapy services were not needed it should have been documented on the initial evaluation.

d) During an interview on 12/28/16 at 3:37 p.m., Therapist #3 stated once an order was received therapy had 72 hours to complete an evaluation. S/he stated an evaluation document should have been filled out. Therapist #3 stated the evaluation determined if there was a need for skilled therapy. S/he stated the completed evaluation form included short and long term goals for therapy. None of this was present in Patient #1's medical record.

e) During an interview on 12/27/16 at 4:06 p.m. Lead Physical Therapist (Manager) #4 stated she oversaw the therapy programs at the facility. Manager #4 stated a note should have been in Patient #1's medical record if s/he was evaluated or treated by a therapist. S/he stated there was no evidence present in the medical record that stated physical therapy evaluated Patient #1. This was against physician orders and facility policy.

f) During an interview on 12/27/16 at 4:31 p.m. Chief Clinical Officer #5 stated if therapy was not documented in the medical record it was not done.

Based on interviews and record review the facility failed to ensure nursing staff performed or had the knowledge of standards of care about intravenous (IV) catheter site changes, peripherally inserted central catheter (PICC line) and central line catheter dressing changes in 6 out of 10 patient records reviewed (Patient #1, #2, #6, #7, #9 and #10).

This failure created the potential for patient harm due to a risk of infection at the IV site and a risk for blood clots.

FINDINGS

REFERENCE

According to Lippincott Procedures - IV Catheter Removal April 15,2016, the use of a short IV catheter is indicated when the anticipated duration of IV therapy is short, less than 6 days. The short peripheral IV catheter should be removed when it's no longer indicated for the patient's plan of care or when it hasn't been used for 24 hours or more. It should be removed when signs and symptoms of complication occur.

According to the Centers for Disease Control and Prevention, a peripheral IV catheter should be replaced no more frequently than every 72 hours to reduce the risk of infection and phlebitis in adults.

1. The facility failed to assure peripheral IV's were maintained according to facility guidelines.

a) Record review for Patient #1 revealed s/he was admitted on 09/16/16 for ongoing wound care from a flap procedure, a surgery done to treat large wounds that cannot be closed by skin grafting. The patient was admitted to the facility with a PICC line which was removed on 10/05/16 and replaced by a peripheral IV in the patient's left upper arm. From 10/05/16 until 10/19/16, the record revealed the IV site was not changed per facility protocol during the 14-day period. There was no order found to show a physician approved extended use of the peripheral IV.

b) Record review for Patient #6 showed s/he was admitted on 07/03/16 for respiratory failure and wound care. Patient #6 arrived with an IV in place and which had a recorded insertion date of 07/01/16. From 07/03/16 until 07/07/16, there was no documentation of IV site change. Additionally, there was no order within the medical record to show the physician had approved extended use of the IV. This was in contrast to the facility requirement for IV sites to be changed every 3 days.

c) Record review for Patient #7 showed the patient was admitted for chronic right sided pleural effusion, a buildup of fluid between the tissues that line the lungs and the chest. A peripheral IV was placed on 10/24/16 with no assessment documented or IV site change for 11 days when it was removed on 11/01/16. No order from the physician was found to approve use of the IV site for an extended time frame. This was in direct contrast to the facilities requirement for IV site changes every 3 days.

d) Record review of Patient # 10 showed s/he was admitted to the facility for wound care after surgical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. On 12/17/16 a peripheral IV was started and was removed on 12/28/16 at midnight. No documentation was noted to show an IV site change occurred for the 11 days the IV was inserted and no order was present from the physician to allow the use of the IV site for an extended period of time.

e) A medical record review for Patient #2 revealed the patient was admitted on 12/20/16 for respiratory care after a motor vehicle accident. The patient initially had a PICC line which was ordered to be removed on 12/21/16 and a an IV was started the same day. There was no documentation of an IV site change for 7 days until the IV was removed on 12/28/16. Additionally, there was no order within the medical record to show the physician had approved extended use of the IV site. This was in contrast to the facility requirement for IV sites to be changed every 3 days.

f) A review of Patient #5's medical record revealed IV documentation was inconsistent. The patient was admitted on 11/17/16 for respiratory failure. On 11/17/16 the medical record reflected the IV site was in the right hand but no documentation was found to show when it was placed. On 11/18/16 documentation showed the IV site was in the left hand but no documentation was present to show when the site change occurred.

From 11/21/16 to 11/23/16, for 2 days there was no documentation to show an IV was present. There was no order within the medical record to discontinue the IV site or documentation as to what happened to the IV site. There was no an order found from a physician allowing the use of the IV site for an extended period of time.

g) An interview was conducted with Registered Nurse (RN) #7 on 12/27/16 at 3:06 p.m. According to RN #7 IV's were to be changed every 72 hours and if the insertion date or last IV site change could not be determined the IV site was to be changed immediately. RN #7 stated documentation of IV sites was completed in the IV therapy section in the Daily Nursing Assessment form. RN #7 further stated when there was difficulty placing an IV site a physician could place an order in the medical record to extend the use of an IV site beyond the 72-hour limit.

On 12/28/16 at 1:53 p.m. RN #7 was asked to locate the facility policy on IV site care. RN #7 was unable to locate the policy manual and stated the policy could be reviewed online instead but was still unable to present a policy.

h) An interview was conducted with RN #6 on 12/28/16 at 11:34 a.m. According to RN #6 IV sites were documented in the nursing notes and should include the date of insertion. RN #6 stated an assessment should be completed to determine when the IV needed to be changed. RN #6 stated s/he would need to check the policy book to know when an IV site needed to be changed because s/he did not know what the time frame was to change the IV site.

i) In an interview conducted with RN #9 on 12/28/16 at 11:50 a.m., RN #9 stated s/he would have to check the policy and procedure book to know for sure how often an IV site had to be changed.

j) An interview was conducted with RN #8 on 12/28/16 at 12:28 p.m. According to RN #8 an IV site needed to be changed every 3 days to prevent infection and would be discontinued if the IV site was not being used. RN #8 stated the IV site needed to be assessed daily for infiltration and redness.

k) An interview was conducted with the Chief Clinical Officer (CCO #5) on 12/27/16 at 3:55 p.m. COO #5 stated there was no facility policy concerning IV site changes but the facility followed the Lippincott guidelines which stated the IV site was to be changed every 72 hours. COO #5 stated it was the expectation of the facility that all nurses were aware of the guideline and documented the assessment, change and removal of IV sites within the patient's medical record. Additionally, COO #5 stated if an IV site needed to remain in longer than 72 hours a physician order was required. Upon review of the medical record of Patient #6 COO #5 stated "if it's not documented, it wasn't done".







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2. The facility did not ensure dressings on peripherally inserted central catheter (PICC) lines were changed according to the facility's standard of care and leadership's expectations.

a) A review of Patient #9's medical record revealed s/he was admitted to the facility on 11/23/16 with a right arm PICC line present. The IV therapy section of the Daily Nursing Assessment Form revealed the PICC line dressing was changed on 11/21/16. The medical record revealed on 12/1/16 Patient #9 was transferred to a different facility. There was no evidence the PICC line dressing was changed during the 10 days of Patient #9's stay at the facility.

Further review of Patient #9's medical record revealed on 12/7/16 s/he returned to the facility with a right arm PICC line present. The IV therapy section of the Daily Nursing Assessment Form revealed the PICC line dressing was changed on 12/4/16. The next PICC line dressing change was documented on 12/12/16, 8 days later.

b) During an interview on 12/28/2016 at 11:34 a.m., RN #6 stated s/he would have to check the facility's policies regarding when a PICC line dressing should have been changed. However, during a tour of the facility on 12/28/16 at 1:53 p.m. the facility's policies could not be located by facility staff.

c) During an interview on 12/28/16 at 11:50 a.m., RN #9 stated PICC line dressing changes should have been done every 72 hours.

d) During an interview on 12/28/16 at 2:50 p.m., RN Supervisor #10 stated his/her expectation was the PICC line dressing was changed every 7 days.

e) During an interview on 12/28/16 at 12:09 p.m., CCO #5 stated s/he expected staff to know when PICC line dressings changes were due. S/he stated PICC line dressing changes should have been done every 7 days.