HospitalInspections.org

Based on observation, interview, and record review it was determined that the hospital failed to meet the patient care need for an intravenous access for 1 of 10 sampled patients ( #7).

Findings include:

1) A review of the medical record revealed Patient #7 was an 85 year old female admitted on 5/21/2011 for surgical repair of right hip fracture. The patient was in buck's traction and had orders for an intravenous line, intravenous medications, and was being prepared for surgical repair of the fracture.

On 5/23/2011 at 1554 (3:54 PM) the record revealed the intravenous catheter was discontinued by the primary Registered Nurse (RN). The patient did not receive a replacement intravenous catheter till 2130 (9:30 PM) despite having orders for the access and medications orders for intravenous route. At 2135 (9:35 PM) Patient #7 received an intravenous dose of Dilaudid (pain medication), approximately 6 hours later.

2) An interview was conducted on 10/26/2011 at 1:44 PM with patient #7's primary RN from 5/23/2011. She reviewed the medical record entries and confirmed the intravenous line was discontinued due to "leaking" but she did not insert a replacement line, could not recall if she had notified any other nurse of the need for the line, and failed to document any attempts to meet the patient's need for the access.

3) On 10/26/2011 at 2:20 PM an interview was conducted with the hospital's Executive Director of Nursing. He stated it is not an acceptable standard of care to have a patient who has orders for intravenous access and medications to not have a line and if the line needs replacement the 6 hour delay would be unacceptable.

Correction date November 26, 2011