HospitalInspections.org

Based on policy review, record review, and interview, the hospital failed to ensure nursing services removed the tourniquet after an Intravenous (IV) line was started for 1 of 4 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy "Routine Venipuncture" approved 1/2022 revealed, "...A patient's veins are the main source of blood for laboratory testing as well as a point of entry for IV's...only a few veins are easily accessible...important that everything be done to preserve their good condition and availability...A fresh tourniquet is used with each venipuncture...The time a tourniquet is on the patient should be minimized...not to exceed 1-2 minutes..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 9/16/2022 with a past medical history of Liver Cirrhosis with recent fluid removal, sharp, intermittent abdominal pain, and worsening Shortness of Breath. Chest X-ray showed pleural effusion and right basilar pneumonia. Patient #1 was admitted for further management.

On 9/20/2022, Patient #1 was noted to require more oxygen and was moved to the Intensive Care Unit (ICU).

The Clinical Documentation Record revealed on 9/20/2022 at 4:19 PM, Patient #1 had an IV inserted into her left antecubital (AC) area. The IV was discontinued on 9/21/2022 at 10:00 AM, due to infiltration. An IV was started in the right antecubital area on 9/21/2022 at 10:00 AM.

On 9/22/2022, the patient became unresponsive, and the family decided to send Patient #1 for in-patient hospice care.

Review of the Ambulance Run Report dated 9/22/2022 at 2:45 PM revealed, "...very cold to touch...no physical response...left arm presented with severe edema and bruising with no pulse due to previously placed tourniquet above AC cutting off complete circulation. Left arm had no IV in place. Upon arrival at destination ask...how long her [Patient #1] arm had presented this way, they were unsure and stated that the arm had stayed covered up while in the hospital. Before releasing tourniquet nursing staff at destination was advised to see the condition of the arm. Tourniquet was then released..."

Review of the shift running document from in-patient Hospice #1 dated 9/22/2022 at 2:46 PM revealed, "... RN [Registered Nurse] observed orange tourniquet tied around pt. [patient] mid upper arm. Extremity below tourniquet, anterior and posterior surface of hand and fingers, and all fingernails were deep purple and cold and radial pulse were not palpable. Tourniquet was removed..."

Review of the shift running document from in-patient Hospice #1 dated 9/23/2022 at 8:30 AM revealed, "...Left forearm and hand are black and cold to touch..."

Patient #1 expired on 9/23/2022 at 1:25 PM.

3. In a telephone interview on 11/10/2022 at 1:10 PM, RN #1 was asked about a bath that was documented for Patient #1 on 9/22/2022 at 8:00 AM. RN #1 revealed the bath was a partial bath, not a full bath. RN #1 revealed she did not go on the patient's left side because the family was on that side and Patient #1 was covered in blankets. RN #1 verified that she did not assess Patient #1's left arm before she was discharged to the in-patient hospice facility.