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Based on observations, interview, record review and review of the facility policy and procedure the facility failed to ensure consistent documentation of the date and time intravenous (IV) tubing sets were first started for three of seven patients observed on the Medical/Surgical unit receiving IV fluids. Therefore, they failed to have a system in place to ensure the IV tubing sets were being replaced in 72 hours as required for patient safety. The facility census was 19.

Findings included the following:

1. Review of the facility policy and procedure titled "Sterile Product Preparation" showed the standard of care of the management of sterile product preparation required the following:
- Provide for the delivery of high quality patient care;
- Provide for the safety of patients; and
- Comply with Missouri Division of Health regulation 19 CSR 30-20.021 Organization and Management for Hospitals (g) pharmaceutical services.
Sterile Product Preparation administration guidelines for administering Intravenous (IV) medications by Intermittent Infusion Sets included the following procedure requirements for IV tubing:
- Attach an appropriate IV set to container
- Document date and time set was first used in patient's medical record
- Change sets every 72 hours

2. Observation on 03/23/11 at approximately 8:40 AM, showed Patient #7 was receiving IV fluids running at 100 cc (cubic centimeters) per hour. The IV tubing was not labeled with a sticker to include the date and time the tubing was first used and therefore, did not identify the date required to change the tubing in 72 hours.
Review of Patient #7's record did not include documentation of the date and time the IV tubing was first used.

3. Observation on 03/23/11 at approximately 8:55 AM, showed Patient #14 was receiving IV fluids running at 50 cc per hour. The IV tubing was not labeled with a sticker to include date and time the tubing was first used and therefore, did not identify the date required to change the tubing in 72 hours.
Review of Patient #14's record did not include documentation of the date and time the IV tubing was first used.

4. Observation on 03/23/11 at approximately 9:12 AM, showed Patient #8 was receiving IV fluids running at 75 cc per hour. In addition, the patient was also receiving two different IV antibiotics. The fluid IV tubing and the two tubing's for the antibiotics were not labeled with stickers to include the date and time the tubing's were first used and therefore, did not identify the date required to change the tubing's in 72 hours.
Review of Patient #8's record included documentation of one of the three tubing's with the date and time the IV tubing was first used, but did not identify which of the 3 tubing's was documented.
Note: Because IV fluids and/or IV antibiotics are instilled into the bloodstream, sterile technique is necessary to prevent entry of bacteria into the bloodstream. Changing the IV tubing is normally recommended every 48 to 72 hours (per facility policy) in order to help ensure sterility of the IV solutions.

5. During an interview on 03/23/11 at approximately 10:10 AM, Staff C (Registered Nurse Manager of the Medical/Surgical unit) stated that they have a new electronic system (Meditech) for documenting the date and time the IV tubing is first used. The goal was to start using Meditech instead of using written stickers. However, some nurses are still using the stickers to label the date to change the IV tubing and some aren't. Staff C said, "I guess we are not being consistent". Staff C stated that they have five ward clerks who ideally would add IV tubing as an option in Meditech, which would prompt IV tubing changes every 72 hours as required. Staff C said, "Looks like they are adding the option sometimes, but are not consistent" and "will need to re-train them so that all of them are consistent". Staff C stated that they do not have written policies or procedures for the new system at this point.