HospitalInspections.org

Based on medical record review, document review and interview, in three (3) of three (3) medical records reviewed, it was determined the nursing staff failed to assess the patients' intravenous (IV) sites as per the facility's policy. (Patients #s 1, 2 and 3).

Findings include:

The facility's policy titled "Initiating and Maintaining Continuous and Intermittent IV Therapy," which was last revised 12/18 revealed: maintenance of the IV site includes the site "is checked every four (4) hours for:
a. Phlebitis
b. Signs of infiltration
c. Signs of infection"

Review of the medical record for Patient #1 identified: the patient was admitted to the facility on 7/3/19 for a Urinary Tract Infection and Sepsis. Two heplocks (intravenous catheter), one (1) in the right arm and one (1) in the left arm were inserted in the ED.

The intravenous (IV) site in the patient's right arm was checked at the following times between 7/6/19 to 7/11/19:

7/6/19 at 9:00 PM
7/7/19 at 8:00 PM
7/8/19 at 1:00 PM
7/11/19 at 4:17 PM.

The IV site in the patient's left arm was checked at the following times between 7/7/19 to 7/11/19:

7/7/19 at 8:00 PM
7/9/19 at 8:00 PM
7/10/19 at 8:00 AM
7/11/19 at 8:00 AM.

On 7/9/19 the patient's IV site in the right arm became infiltrated, which resulted in swelling and formation of multiple blisters on the right arm. On 7/25/19 the patient had a 13 cm x 10 cm wound on the hand with necrotic (dead) tissue, which required Collagenase (substance that help wounds heal faster) dressings and a plastic surgery consultation. The patient was also diagnosed with Cellulitis of the right hand.

There was no evidence that the patient's IV sites were assessed every four (4) hours as required in the policy.

Review of the Medical record for Patient #2 identified: the patient was admitted to the facility on 2/15/19 with a diagnosis of a stroke. The patient received antibiotic medication via a left forearm IV catheter (heplock). The patient's IV catheter site was checked on the following occasions between 2/16/19 and 2/18/19:

2/16/19 at 1:00 AM
2/16/19 at 10:00 AM
2/16/19 at 8:00 PM
2/17/19 at 8:00 AM
2/18/19 at 10:49 AM.

The patient's IV site was found to be infiltrated and swollen on 2/18/19 at 3:00 PM.


Review of the medical record for Patient #3 identified: this patient was admitted to the facility on 1/31/19 because he had refused dialysis for two (2) weeks. During the patient's hospitalization the patient developed gastrointestinal bleeding for which he was given multiple units of blood and antibiotics were given intravenously for a toe infection. The IV site was checked on 2/10/19 to 2/12/19 at the following times:

2/10/19 at 8:00 PM
2/11/19 at 8:00 AM
2/12/19 at 8:00 AM

The patient's right hand IV site was found to be infiltrated on 2/13/19 at 12:50 PM, when phlebitis and swelling were noted.

The nursing staff failed to assess the patients' intravenous sites every four (4) hours as required in the facility's policy.

These findings were shared with Staff A, the Director of Nursing on 10/15/19 at approximately 2:00 PM.

Based on interview and in one (1) of one (1) medical record reviewed, it was determined that the dietitian failed to collaborate with other members of the clinical team (nursing and physician) to plan and implement patient care to ensure the nutritional needs of the patients are met.


Findings include:

Review of the medical record for Patient #1 identified: A 73-year-old patient with a past medical history of Diabetes, Hypertension and Hypothyroidism. The patient was admitted to the facility on 7/3/19 for a Urinary Tract Infection, Sepsis, increased lethargy, weakness and decreased appetite. In the "Nutrition initial Assessment" completed on 7/4/19, the dietitian noted a history of Percutaneous Endoscopic Gastrostomy (PEG), questionable dysphagia/inability to consume adequate oral intake; PEG not in use at this time and that the patient was tolerating regular textures prior to admission. She noted the patient's weight as 170 lb. and estimated his nutritional needs. Her recommendations were to continue with the current diet regimen of regular diet, aspiration precautions, enteral tube feeding if unable to tolerate PO diet, a formal swallow evaluation and to monitor the patient's weights weekly.

Nutrition notes on 7/6/19 indicated the patient's currently receiving PEG feeding. She noted that the patient was unable to take PO diet and when medical feasible and patient's mental status improved, may suggest Speech Language Pathologist (SLP) evaluation to determine proper PO diet consistency.

Nutrition follow-up assessment on 7/9/19 noted the patient's weight as 174.3 lb and a plan to monitor the weight weekly.

On 7/16/19 Nutrition follow-up assessment, weights were documented as follows:
7/4 - 170 lb
7/5 - 176.2 lb
7/6 - 175.5 lb
7/9 (RD bed scale) -174.3 lb
7/11 - 198 lb
7/16 - 183 lb.
The dietitian noted that the weight was trending approximately (~)175 lbs then a questionable 20 lb gain, now trending back down. Possible fluid /swelling versus bed scale discrepancies.

On 7/23/19 Nutrition follow-up assessment weights:
7/18 - 174 lb
7/19 - 172.5 lb
7/20 - 171.96 lb
7/23 - 178.7 lb.
The dietitian noted ~5.29% weight change over seven (7) days, likely related to bed scale error in view of marked fluctuations noted per weight data and that she will continue to monitor/trend weight.

On 7/27/19 Nutrition follow-up assessment: the dietitian noted the patient's weight to be 169.3 lb and that she questioned today's nurse flow sheet weight, changes possibly fluid /swelling related versus bed scale discrepancies, will continue to monitor.

On 7/29/19 Nutrition follow-up notes: the dietitian noted that the patient is on 24 hour continuous tube feeding and oral meal and recommended switching feed to run 16 hours to improve oral intake. She recommends changing tube feeding to a renal formula and will start a three (3) day calorie count.

There was no assessment of the weight loss in correlation to intake.

On 8/1/19 Nutrition follow-up assessment: the patient's weight was 145.6 lb. The dietitian noted significant weight loss versus fluctuation, though difficult to obtain true weight given many different items on bed. She questions today's nurses' flow sheet weight and will continue to trend.

On 8/3/19 Nutrition follow-up assessment noted the 3-day calorie count was completed with overall inadequate PO intake.

On 8/7/19 Nutrition follow-up assessment indicated patient's weight today was 144 lb. She wrote that the weight continued to trend downward, difficult to assess true weight throughout hospitalization due to bed scale discrepancies/swelling /multiple pillows on bed and that true loss possible related to poor oral intake and supplemental tube feeding.


During interview with the Staff B, Registered Dietitian on 9/14/19 at approximately 1:00 PM, she stated that discrepancies in weight was possible due to fluid/swelling versus bed scale discrepancies. She stated that she did not discuss the weight changes with the nursing staff.

The documentation in the medical record showed the patient weighed 170 lbs on 7/4/19 and 136.68 lbs on 8/9/19, reflecting a total weight loss of 33.32 lb. Throughout his hospitalization the patient's weight loss was not evaluated and addressed. There was no correlation made with the patient's nutrient intake and his weight loss. Nor was there a discussion with the nursing staff regarding the accuracy of the weights. The dietitian continued to write in her follow-up notes that weight loss was possible due to fluid/swelling versus bed scale discrepancies but there was no documentation of a discussion with the clinical staff.

The dietitian recommended and suggested swallow evaluation to assess patient's PO diet consistency and aspiration precautions on the initial nutrition assessment 7/4/19 and on subsequent nutrition follow-up assessments through 8/7/19. However there was no documentation in the medical record showing that she spoke with the physician regarding her recommendations and if he agreed with the recommendations. Therefore the patient's ability to swallow PO intake was not fully addressed.

During interview on 10/14/19, the Registered Dietitian stated that she spoke with the patient's physician regarding an SLP evaluation to assess the patient's PO intake and aspirations precautions and he stated that the patients is able to swallow so there was no need for the SLP evaluation.

These findings were shared with Staff A, the Director of Nursing and Staff B, Registered Dietitian on 10/15/19 at approximately 1:30PM.