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Based on observation and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by non-functioning nurse call buttons on the hand rails of patient beds for 32 of 32 beds located in the inpatient unit at the offsite location. This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the nurse call button on the bed hand rail rather than the hand held call light.

Findings:

In an observation on 07/02/2024 at 3:56 p.m. of the inpatient unit at the offsite location revealed the patient beds in rooms 'a' and 'b' had non-functioning nurse call buttons on the hand rails.

In an interview during the observation S3SDN verified all 32 patient beds had non-functioning nurse call buttons on the hand rails.

Based on record reviews and interviews, the hospital failed to ensure a nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by failure to document a complete IV assessment per hospital policy on 3 of 3 (#1, #2, #3) patients reviewed.

Findings:

Review of the hospital's policy titled "Insertion, Maintenance, & Discontinuation of IV therapy for all lines in adults (18Y or older) Peripheral IV, Midline, Medi port, PICC, Central Lines, and Art lines, Intraosseous Access" revision date 07/2023, revealed in part, Peripheral IV policy: 2.) Assess site every 4 hours and document phlebitis scale, infiltration scale.

Patient #1
Review of Patient #1's medical record revealed an admission date of 06/28/2024. Further review revealed Patient #1 had a left wrist 20 gauge IV that was placed on 06/28/2024 at 12:50 p.m. and removed on 07/02/2024 at 3:00 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments:
07/02/2024 at 8:00 a.m.
07/02/2024 at 12:00 p.m.

Patient #2
Review of Patient #2's medical record revealed an admission date of 05/14/2024. Further review revealed Patient #2 had a right foreman 20 gauge IV that was placed on 05/14/2024 at 7:07 p.m. and removed on 05/16/2024 at 3:24 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments:
05/15/2024 at 12:00 a.m.
05/15/2024 at 3:39 a.m.
05/15/2024 at 8:00 p.m.
05/16/2024 at 12:00 a.m.
05/16/2024 at 4:00 a.m.

Patient #2 had a left forearm 22 gauge IV that was placed on 05/14/2024 at 9:32 p.m. and removed on 05/16/2024 at 3:26 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments:
05/15/2024 at 12:00 a.m.
05/15/2024 at 3:39 a.m.
05/15/2024 at 8:00 p.m.
05/16/2024 at 12:00 a.m.
05/16/2024 at 4:00 a.m.

Patient #2 had a left hand 22 gauge IV that was placed on 05/16/2024 at 3:25 p.m. and removed on 05/22/2024 at 3:24 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments:
05/16/2024 at 8:00 p.m.
05/17/2024 at 12:00 a.m.
05/17/2024 at 4:00 a.m.
05/17/2024 at 8:00 a.m.
05/17/2024 at 12:00 p.m.
05/17/2024 at 4:00 p.m.
05/17/2024 at 8:00 p.m.
05/18/2024 at 12:00 a.m.
05/18/2024 at 4:00 a.m.
05/18/2024 at 8:00 p.m.
05/18/2024 at 11:49 p.m.
05/19/2024 at 3:28 a.m.
05/19/2024 at 8:00 p.m.
05/19/2024 at 11:18 p.m.
05/20/2024 at 3:40 a.m.
Further review revealed there was no documentation of an IV assessment every 4 hours on 05/19/2024 from 8:00 a.m. - 8:00 p.m. and on 05/20/2024 from 3:40 a.m. - 12:00 p.m.

Patient #2 had a right hand 22 gauge IV that was placed on 05/16/2024 at 3:25 p.m. and removed on 05/22/2024 at 3:24 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments:
05/16/2024 at 8:00 p.m.
05/17/2024 at 12:00 a.m.
05/17/2024 at 4:00 a.m.
05/17/2024 at 8:00 a.m.
05/17/2024 at 12:00 p.m.
05/17/2024 at 4:00 p.m.
05/17/2024 at 8:00 p.m.
05/18/2024 at 12:00 a.m.
05/18/2024 at 4:00 a.m.
05/18/2024 at 8:00 p.m.
05/18/2024 at 11:49 p.m.
05/19/2024 at 3:29 a.m.
05/19/2024 at 8:00 p.m.
05/19/2024 at 11:18 p.m.
05/20/2024 at 3:40 a.m.
Further review revealed there was no documentation of an IV assessment every 4 hours on 05/19/2024 from 8:00 a.m. - 8:00 p.m. and on 05/20/2024 from 3:40 a.m. - 12:00 p.m.

Patient #3
Review of Patient #3's medical record revealed an admission date of 07/02/2024. Further review revealed Patient #3 had a right hand 20 gauge IV that was placed on 07/02/2024 at 1:38 a.m. and removed on 07/04/2024 at 11:40 a.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessment:
07/04/2024 at 8:00 a.m.
Further review revealed there was no documentation of an IV assessment every 4 hours on 07/02/2024 from 1:39 a.m. - 4:00 p.m.

In an interview on 07/08/2024 at 2:12 p.m. S2DR verified IV assessments should be documented every 4 hours. S2DR verified the nurse should have documented the phlebitis scale and infiltration scale every 4 hours according to hospital policy.