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Based on interviews (D, E, F) and tours for 1 of 1 patients (#1) the facility failed to ensure patients are given a safe environment where they are able to contact staff for assistance. This deficient practice has the potential to affect all patients at this facility.

Findings include:

Per interview with RN E on 5/11/13 at 2:00 PM via conference call with Director of Medical/Surgical/ICU F, RN E stated Pt #1 was moved temporarily to the family lounge due the 2nd patient in that room needing immediate medical attention when a Rapid Response (an emergent situation where the patient is having a rapid decline in condition) was called . Per RN E the patient would not have been in the lounge for more than an hour. To RN E's knowledge there is not a call light in the lounge. RN E believed there to be a pull cord in the lounge bathroom. RN E stated the patient was placed in the lounge because at the time of the Rapid Response they did not have time to move him to another patient room. To RN E's knowledge no one was with Pt #1 during that time in the lounge.

A tour of fifth floor unit was conducted on 12/9/2013 at 2:00 PM accompanied by Unit Manager D, Director of Medical/Surgical/ICU F and Improvement specialist A. The family lounge does not have a call light and the family lounge bathroom does not have a pull cord. The lounge contained one recliner chair and one couch. Per Unit Manager D at the time of the tour, patients should not be placed in the lounge area.

Based on MR review, P&P review and interview (A), in 4 of 4 MR (#1, 2, 3, 4) with IV rate changes in a total universe of 10 MR's, the facility failed to ensure IV orders are completed and documented as ordered by the physician. This deficient practice has the potential to affect all patients receiving IV therapy at this facility.

Findings include:

Per review of facility policy titled "Peripheral Intravenous Therapy: Insertion, Maintenance, Discontinuation" on 12/9/2013 at 1:40 PM under documentation it states "2. Document infusion rate and rate changes, including the time that the change was implemented."

Per review of Pt #1's MR on 12/9/2013 at 11:30 AM accompanied by Improvement Specialist A, at 11:20 AM on 4/14/2013 an order was written by the physician for NS (normal saline) to be infused via IV at 60 ml's per hour. At 1:55 PM on 4/14/2013 an order was written by the physician for the NS infusion to be increased to a rate of 75 ml's per hour. There is no documentation that IV infusion was started prior to 2:01 PM therefore missing the first order and there is no documentation on the rate the IV was infusing at and if/or when it was increased.

Per review of Pt #2's MR on 12/9/2013 at 2:30 PM accompanied by Patient Safety Manager C, at 8:10 AM on 9/10/2013 on order was written by the physician for NS to be infused via IV at 150 ml's per hour. On 9/11/2013 at 12:20 PM an order was written by the physician to decrease the NS infusion to 100 ml's per hour. On 9/11/2013 at 9:00 PM an order was written by the physician to decrease the NS infusion to 75 ml's per hour. There is no documentation the IV infusion was decreased as ordered by the physician.

Per review of Pt #3's MR on 12/9/2013 at 1:30 PM accompanied by Patient Safety Manager C, at 5:40 PM on 7/8/2013 an order was written by the Physician for NS to be infused via IV at 100 ml's per hour. On 7/9/2013 at 10:45 AM an order was written to increase IV infusion to 125 ml's per hour. There is no documentation the IV infusion was increased as ordered by the physician.

Per review of Pt #4's MR on 12/9/2013 at 1:15 PM accompanied by Improvement Specialist A, at 8:40 AM on 12/5/2013 on order was written by the physician for NS with Potassium to be infused via IV at 125 ml's per hour. On 10/6/2013 on order was written by the physician to decrease the IV infusion to 50 ml's per hour. There is no documentation the IV infusion was decreased as ordered by the physician.

Per interview with Clinical Applications Analysis B on 12/9/2013 at 1:30 PM the facility does not currently document when an IV rate is changed.