HospitalInspections.org

Based on document review and interview the hospital failed to document a site assessment when discontinuing a PIV (Peripheral Intravenous) line in one of 10 patients. (P10)

Findings include:

1. Facility policy titled, Peripheral Intravenous (PIV) Care, PolicyStat ID 10774903, last approved 10/5/2023, indicated when discontinuing a PIV, document date and time of removal and a site assessment.

2. P10's medical record indicated LDA (Lines, Drains and Airway) documentation indicated PIV access placements and removals as follows:
a. 9/15/23: At 9:57 am, 20 G (Gauge), Left Antecubital, PIV, 2 attempts, ED (Emergency Department). Removed by patient at 1:00 pm. At 1:29 pm, 20 G, Left Upper Arm ,US (Ultrasound Guided), PIV, 1 attempt, ED. Removed by patient at 9:30 pm. At 10:09 pm, 20 G, Right Anterior Upper Arm, US guided, PIV, 1 attempt, AA (Acuity Adaptable). Removed by patient at 11:07 pm. At 11:17 pm, 18 G, Right Anterior Upper Arm, US guided, PIV, 2 attempts, AA. Removed d/t occlusion on 9/16/23 at 8:00 pm.
b. 9/16/23: At 8:15 pm, 20 G, Right Anterior Distal Forearm, US guided, PIV, 1 attempt, AA. Removed d/t dislodgement on 9/17/23 at 3:30 am.
c. 9/17/23: At 10:00 am, 20 G, Left Anterior Upper Arm, PIV, 1 attempt, AA. Removed d/t no longer indicated on 9/18/23 at 12:24 pm.
d. The MR lacked documentation of site assessments after discontinuation of PIV's.

3. In interview on 10/25/23 at 12:30 pm with hospital staff N1 (Registered Nurse) confirmed no post PIV removal site assessments were completed for this patient and should have been.