HospitalInspections.org

Based on document review and interview, it was determined that for approximately 70 resource nurses, the Hospital failed to ensure that all staff nurses and clinical resource nurses responsible for caring for patients were educated on the removal of intravenous (IV) access devices prior to being discharged.

Findings Include:

1. The Hospital's policy titled, "Discharge of Patients" (revised 6/1/16) was reviewed on 4/24/18 and required, " ...Purpose ...to safely discharge patients ..." The policy lacked instructions for discharge procedures for patients with IV access.

2. Pt. #1's clinical record was reviewed on 4/23/18 at 11:00 AM. Pt. #1 was a 86 year old male, admitted on 4/3/18 with the diagnoses of jaundice (yellowing of the skin and whites of the eyes), elevated liver function tests, abdominal pain, and possible pancreatic cancer (diagnosis has not been confirmed). The emergency room nurse's (E #12) note dated 4/3/18 at 12:31 PM included, "left chest port (implanted vascular device) accessed with 20 g (gauge) 1 inch needle." A Registered Nurse on 5 West (E #5's) note dated 4/8/18 included, " ...Patient (Pt. #1) discharged back home..."

3. On 4/23/18 at 3:05 PM, a telephone interview was conducted with the Registered Nurse (E #5) who discharged Pt. #1 on 4/8/18. E #5 stated that a Nurse's Aide assisted Pt. #1 with getting dressed before discharge and she (E #5) didn't know Pt. #1's porta cath (implanted vascular device) still had an IV attached. E #5 stated that the IV should have been removed before discharge.

4. An interview was conducted on 4/24/18 at 9:36 AM with a 5 West Unit Charge Nurse (E #7). E #7 stated that Pt. #1 came back to the Hospital on 4/8/18 and the port was de-accessed (removal of needle and tubing) with no problems identified.

5. An interview was conducted on 4/24/18 at 10:10 AM with E #10 (Chief Nursing Officer/Chief Operations Officer). E #10 stated that there was a managerial meeting held on 4/9/18 to follow-up on the accessed port concern and the staff decided to implement a discharge checklist. E #10 stated that the staff on 5 West Unit were re-educated on discharge procedures which included de-accessing ports. E #10 stated that there are no attendance sign in sheets for staff re-education related to discharge procedures and port de-accessing.

6. An interview was conducted on 4/23/18 at 1:43 PM with the Manager of Nursing Operations (E # 9). E #9 stated that E #5 is from the Hospital's Clinical Resource Team. There are approximately 70 resource nurses who work part-time. E #9 stated that the Clinical Resource Team nurses are utilized to provide staff support to the Hospital nursing units when needed. E #9 stated that the Clinical Resource Nurses were re-educated during daily huddles and by electronic mail newsletters on discharge procedures, which included de-accessing ports. E #9 stated that there are no attendance sign-in sheets for the Hospitals Clinical Resource Team to verify re-education during daily nursing huddles or electronic mail.

7. On 4/231/8 at 3:05PM, during a telephone interview E #5 stated that she did receive counseling for the incident invoving Pt. #1, but had not attended a huddle where the incident was discussed.

Based on document review and interview, it was determined that for 1 of 4 clinical records reviewed (Pt. #1) for patients with implanted intravenous (IV) access devices, the Hospital failed to ensure that the IV devices were closed and tubing discontinued prior to discharge.

Findings Include:

1. The Hospital's policy titled, "Discharge of Patients" (revised 6/1/16) was reviewed on 4/24/18. The policy included, " ...Purpose...to safely discharge patients ..." The policy lacked instructions for discharge procedures for patients with IV (intravenous) access.

2. Pt. #1's clinical record was reviewed on 4/23/18 at 11:00 AM. Pt. #1 was an 86 year old male, admitted to the Hospital on 4/3/18 with the diagnoses of jaundice (yellowing of the skin and whites of the eyes), elevated liver function tests, abdominal pain, and possible pancreatic cancer (diagnosis has not been confirmed). The emergency room nurse's (E #12) note, dated 4/3/18 at 12:31 PM included, "left chest port (implanted vascular device) accessed with 20 g (gauge) 1 inch needle." Pt. #1's infusion port had been placed prior to admission, for chemotherapy. Pt. #1's medication administration record included, the port was used to administer Lasix (for fluid removal) and Potassium Chloride (to increase Potassium levels) during this admission. Pt. #1's nursing notes dated 4/8/18 included, " ...Patient (Pt. #1) discharged back home...IV removed..."

3. A telephone interview was conducted on 4/23/18 at 3:05 PM with a Registered Nurse (E #5). E #5 stated that she (E #5) discharged Pt. #1 on 4/8/18. E #5 stated that Pt. #1's port was not de-accessed before discharge and Pt. #1 left the Hospital with a catheter in his left chest port. E #5 stated that she (E #5) documented that Pt. #1's IV was removed in error. E #5 stated that she (E #5) had recently discharged another patient whose IV was discontinued and mistakenly included it in Pt. #1's notes.

4. An interview was conducted on 4/24/18 at 9:36 AM, with a 5 West Unit Charge Nurse on 4/8/18, from 7:00 PM - 7:00 AM (E #7). E #7 stated that Pt. #1 came back to the Hospital on 4/8/18 and the port was de-accessed with no problems identified.

5. An interview was conducted on 4/23/18 at 1:00 PM with an Oncologist (MD #1). MD #1 stated that it is not standard practice to leave a port accessed upon discharge. MD #1 stated that, unless there is a Physician's order to keep the port access in place, a port should be de-accessed upon discharge. MD #1 stated that, if a port is left accessed for too many days, there is an increased risk of infection.

6. An interview was conducted on 4/23/18 at 12:28 PM with the Nurse Manager of the 5 West Unit (E #8). E #8 stated that Pt. #1's port should've been de-accessed (removal of needle and tubing) prior to Pt. #1's discharge from the Hospital.

Based on document review and interview, it was determined that for 2 of 3 (Pt. #2 and Pt. #3) clinical records reviewed for patients central venous catheters (CVC's), the Hospital failed to ensure that a care plan was developed for CVC care.

1. On 4/23/18 at 1:30 PM, the Hospital's policy titled, "Interdisciplinary Care Planning" (revised 1/1/17) was reviewed and required, "...Interdisciplinary communication is essential to ensure that the patient, family, and members of the care team understand the anticipated goal(s)/outcomes(s), patient/family educations, and the plan of care...The Registered Nurse initiates the care plan based on identified problems, using the Interdisciplinary Plan of Care within 24 hours..."

2. On 4/23/18 at 9:30 AM, Pt #2's clinical record was reviewed. Pt #2 was a 51 year old female admitted to the Hospital on 4/18/18 with the diagnosis of chronic leg ulcers. Pt #2's IV (intravenous) Site/Line Assessment dated 4/18/18 included "...Left subclavian implanted port...intact...patent..." Pt #2's care plan lacked documentation regarding Pt #2's plan of care for left subclavian (central venous) implanted port care.

3. On 4/23/18 at 9:40 AM, Pt # 3's clinical record was reviewed. Pt #3 was 78 year old female admitted to the Hospital on 3/28/18 with the diagnosis of AML (Acute Myeloid Leukemia). Pt #3's IV Site/Line Assessment dated 4/17/18 included "...Central line insertion dated 4/3/18..." Pt #3's care plan lacked documentation regarding Pt #3's plan of care for central venous catheter.

4. On 4/23/18 at 11:15 AM, an interview was conducted with the Assistant Patient Care Manager (E #2). E#2 stated that Pt #2 & Pt #3's care plan did not include a plan of care for central line catheter care.

Based on document review and interview, it was determined, that for 1 of 2 clinical records reviewed (Pt. #8) for patients receiving insulin (medication to decrease blood sugar), the Hospital failed to ensure insulin was administered as ordered.

Findings include:

1. On 4/24/18 at 12:45 PM, the Hospital's policy titled, "Medication Administration" (revised 2/2/18) was reviewed. The policy required, "D. Administration Process... 5... If medication was not administered due to patient refusal or another reason... Document the reason on the MAR [medication administration record]..."

2. On 4/24/18 at 11:00 AM, Pt. #8's clinical record was reviewed. Pt. #8 was a 79 year old female, admitted on 4/12/18, with diagnoses of decubitus skin ulcer (bedsore), diabetes mellitus, and dementia. Pt. #8's physician's order dated 4/13/18, required novolog insulin administration on a sliding scale for glucose (blood sugar) greater than 141 mg/dL (milligrams per deciliter) as follows:

glucose (mg/dL): insulin (units):

141 - 180 2
181 - 220 4
221 - 260 6
261 - 300 8
301 - 350 10
351 - 400 12
greater than 400 14

Pt. #8's laboratory results included:

- On 4/21/18 at 8:46 PM, a glucose level of 246 mg/dL (requiring 6 units of Novolog)

- On 4/23/18 at 9:03 PM, a glucose level of 315 mg/dL (requiring 10 units of Novolog)

3. Pt. #8's MAR (medication administration record) dated 4/21/18, indicated that the ordered Novolog 6 units for Pt. #8's glucose of 246 was "held", but did not document the reason. Pt. #8's MAR dated 4/23/18, indicated that the ordered Novolog 10 units for Pt. #8's glucose of 315 was not administered. There was no nursing note on 4/23/18 related to insulin not being administered.

4. On 4/24/18 at 11:05 AM, an interview was conducted with the 5 West Unit Manager (E #8). E #8 stated that Pt. #8 should have received 6 units of novolog insulin on 4/21/18, 10 units on 4/23/18, and the reason for not administering the insulin was not documented.