HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure staff followed their policy and notified the medical physician when one expired patient (#23) of one discharged patient reviewed, received a critical diagnostic result of the presence of an acute deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin) (A-0395);
- Ensure three current patients (#6, #37, and #38) of three current patients at risk for falls were protected from falls; two discharged patients (#23 and #35) of four discharged patient charts reviewed were protected from injury when they fell in their room and an injury resulted; and that staff implemented appropriate interventions based on the fall risk assessment for nine current patients (#37, #39, #40, #41, #42, #43, #45, #46, and #47) of 12 current patients observed for fall precautions and interventions (A-0395); and
- Follow their policy for intravenous (IV, in the vein) site dressings for 15 patients (#1, #2, #3, #5, #7, #10, #11, #14, #16, #18, #19, #20, #21, and #22) of 23 current inpatients and failed to remove an IV initiated prehospital for one patient (#15) of one current inpatient (A-0395).

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation (CoP): Nursing Services. The hospital census was 76.

These failures created an unsafe environment and had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 12/15/22, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- Revised the Imaging Critical Results policy to clarify what licensed clinical personnel could accept critical results;
- Educated all hospital based physicians and radiology physicians regarding the revised policy that addressed what licensed clinical personnel could accept critical results;
- Educated all nursing staff prior to the start of their next shift, about what actions to take when they received a critical result; and
- Educated all Radiology staff prior to the start of their next shift on the Imaging Critical Results policy.

As of 12/21/22, the hospital had provided an immediate action plan sufficient to remove the additional IJ when the hospital implemented the following actions:
- Immediate education would be provided to all nursing and unlicensed assistants, prior to their next worked shift, regarding specific interventions related to low, moderate, and high fall risk patients;
- Immediate house wide review of all patients was conducted to verify current fall risk score assessment and for accuracy and appropriateness of fall risk precautions and interventions; and discrepancies were immediately corrected; and
- A SWARM (Mini Root Cause Analysis [RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause] that is conducted within two weeks of the date of the event) would be completed on all falls that resulted in harm to the patient.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure staff followed their policy and notified the medical physician when one expired patient (#23) of one discharged patient reviewed, received a critical diagnostic result of the presence of an acute deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin);
- Ensure three current patients (#6, #37, and #38) of three current patients at risk for falls were protected from falls; two discharged patients (#23 and #35) of four discharged patient charts reviewed were protected from injury when they fell in their room and an injury resulted; and that staff implemented appropriate interventions based on the fall risk assessment for nine current patients (#37, #39, #40, #41, #42, #43, #45, #46, and #47) of 12 current patients observed for fall precautions and interventions; and
- Follow their policy for intravenous (IV, in the vein) site dressings for 15 patients (#1, #2, #3, #5, #7, #10, #11, #14, #16, #18, #19, #20, #21, and #22) of 23 current inpatients and failed to remove an IV initiated prehospital for one patient (#15) of one current inpatient.

Findings included:

1. Review of the hospital's policy titled, "Critical Tests-Reporting Results to Nurses and Physicians," dated 09/11/19, showed the following:
- Critical results are results that fall significantly outside the normal result ranges as articulated in the policies of hospital departments, including imaging services.
- Licensed personnel are responsible for communicating critical results to physicians or designees or other responsible licensed caregivers that can act upon the result.
- Physicians who discover a critical value are expected to directly contact the referring physician.
- If the nurse is the one receiving the results, he/she is responsible to relay the value directly to the appropriate physician.
- When reporting critical results via telephone or in person, include the licensed caregiver who can act upon the result, the patient's name and second patient identifier, the critical result, and any other pertinent information about the result.
- The notification is to be documented in the patient's medical record and should include the time called, name of the physician or caregiver that can act upon the result, the response of the physician or caregiver, and the critical result.

Review of the hospital's policy titled, "Washington Critical Test Results Policy on Critically Ill Patients," dated 11/10/22, directed radiology physicians to immediately call the ordering physician for physician to physician communication with critical test results.

Review of the medical record for Patient #23 showed that he was a 59-year-old male who presented to the Emergency Department (ED) on 10/30/22 at 9:46 AM, with a complaint of right leg pain for a week. Patient #23's medical record showed a Doppler (high-frequency sound wave that measure the amount of blood flowing through blood vessels) study of the right leg was performed on 10/31/22 at 11:40 AM, and showed an acute DVT in the right lower leg. The Doppler study report included a note which showed the critical result findings were telephoned by Staff UU, Radiologist, to Staff LL, Licensed Practical Nurse (LPN), on 10/31/22 at 12:33 PM. Patient #23's medical record did not contain any documentation by Staff LL of having received the critical result notification or having forwarded the result to the attending physician.

During an interview on 12/13/22 at 9:15 AM and at 3:30 PM, Staff LL, LPN, stated that:
- She did not know where to access nursing policies on the floor.
- She would notify the hospital's Quality Office if she had a question regarding a patient care policy.
- On 10/31/22, she received a call from a radiology technician regarding a blood clot identified in Patient #23's ultrasound study.
- She forgot to notify the patient's physician of the result and did not document that she received the result in the patient's medical record.

During an interview on 12/13/22 at 9:40 AM, Staff C, Registered Nurse (RN), Nurse Manager, stated that critical imaging results were to be relayed directly to the ordering physician.

During an interview on 12/13/22 at 1:55 PM, Staff K, RN, Patient Safety Specialist, stated that when critical results were identified, the hospital's policy stated that the radiology physicians would directly notify the attending physician of the results.

During a telephone interview on 12/14/22 at 3:25 PM, Staff UU, Radiologist, stated that when he had a critical result to report for an inpatient, he would call the floor and speak with the patient's doctor or nurse. When he reported a critical result to a nurse, he would expect that the nurse would document the result and notify the physician of the results.

During an interview on 12/14/22 at 11:13 AM, Staff EE, Radiology Manager, stated that the hospital policy for reporting critical radiology results directed staff to provide a physician to physician report.

During a telephone interview on 12/14/22 at 3:40 PM, Staff VV, Hospitalist, stated that when a nurse was notified of a critical result, he would expect the nurse to notify the physician.

During an interview on 12/14/22 at 1:07 PM, Staff M, Chief Nursing Officer (CNO), stated that she would expect that when a nurse accepted a critical result, it would be communicated to the physician.

During an interview on 12/14/22 at 1:45 PM, Staff TT, Chief Medical Officer (CMO), stated that critical results should be reported physician to physician. If a nurse received a critical result, she would expect the nurse to notify the physician within an hour.

Patient #23 presented to the ED with right lower leg pain. The patient was admitted to the hospital and a routine Doppler study was ordered to rule-out the presence of a DVT. The Doppler study results were reported to the patient's primary nurse by the radiologist that read the diagnostic test. The critical result of a DVT was not relayed by the nurse to the attending physician and no medical management for the DVT was initiated. Patient #23 had an unwitnessed fall and died 15 hours after the DVT was diagnosed.

2. Review of the hospital's policy titled, "Washington Administration Fall Precautions," dated 01/10/20, directed staff to:
- Assess all patients to determine their risk of experiencing a fall and initiate and maintain the appropriate precautions. Additional individualized interventions will be implemented, as appropriate, based on the patient's assessed risk.
- Assess patients using the Hester Davis Scale for Fall Risk Assessment (HDS, a tool developed to predict anticipated falls in adult patients in a variety of settings) to determine low, moderate, and high fall risk.
- Complete HDS assessments upon admission, daily, whenever there are changes in the patient's functional or cognitive status, and after a fall occurs.
- Low Fall Risk scores are less than or equal to 10 and precautions include: patient identification (ID) bracelet on, place the call light within reach, keep the bed in a low position with the bed brakes on, orientation to environment and equipment safety, if needed, provide nonskid slipper socks for patients able to walk, educate patient and family on fall prevention program, and note fall risk on all situation-background-assessment-recommendation (SBAR, a communication technique used between members of a health care team about a patient's condition) communication forms.
- Moderate Fall Risk scores are 11-14 and include all of the low fall risk precautions and the following; use of a gait belt (safety device that can be used to help a patient sit, stand or walk around, as well as to transfer them from a bed to a wheelchair and vice versa) while up, fall risk yellow armband, fall risk doorway identifier (fall risk sign), assistance with toileting, educate the patient and/or family on fall risk prevention, activate the safety care plan, enter fall risk status into the electronic health record (EHR), coworker remains in close proximity when the patient requires assistance with walking or is being transported, initiate the bed alarm and chair alarm, and note fall risk score on all SBAR communications forms.
- High Fall Risk scores are 15 or greater and include all the Low and Moderate Fall Risk Precautions and the following; consider using a low bed, consider the need for physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) or occupational therapy (OT, focuses on the use of fine motor and cognitive skills to perform tasks required in daily life) evaluation and treatment request, provide non-skid yellow slipper socks for patients able to walk, consider the use of one to one (1:1, continuous visual contact with close physical proximity) patient care if the patient is confused, has cognitive impairment, repeatedly gets out of bed, repeatedly turns off their own bed alarm (by patient or family members), and is a high fall risk, and note fall risk on all SBAR communication forms.
- At any time additional interventions may be implemented to best fit the patient need and per nursing judgment.

Review of the medical record for Patient #6 showed the following:
- She was an 88-year-old female who was brought to the ED on 12/09/22 after a fall at home with a history of mental status changes and multiple falls in her home.
- Nursing documentation showed HDS ranging from 15 to 28 on 12/10/22 and 12/11/22 and the patient was identified as a high fall risk. Fall precaution interventions that were documented included non-skid socks, bracelet identifying fall risk, fall risk signage on the patient's door, a bed alarm and frequent rounding.
- No HDS or fall risk documentation was present in nursing assessments for Patient #6 on 12/12/22 prior to a nursing note that documented her fall.
- A nursing note documented that Patient #6 was found on the floor on 12/12/22 at 5:11 PM, after staff heard an alarm in her room.
- The patient was assessed and found to have bleeding from her head and a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the head was ordered. The CT showed a subdural hematoma (a pool of blood between the brain and it's outermost covering) which was not documented on previous scans.
- The nursing note showed after the fall on 12/12/22, a sitter was placed with Patient #6 in addition to reactivation of her bed alarm.

Review of the medical record for Patient #37 showed the following:
- She was a 41-year-old female admitted on 12/09/22 with a complaint of generalized weakness.
- Nursing documentation on 12/10/22 at 6:15 PM showed she was able to walk with the assistance of one staff member, used a walker and a gait belt.
- On 12/11/22 at 10:05 PM, her HDS score was a 7, which placed her at a low risk for falling, but fall risk per nursing judgment showed Patient #37 was a moderate fall risk.
- A clinical note from 12/12/22 at 1:40 PM by Staff F, RN, Nurse Manager, Seventh Floor, showed on 12/12/22 at 9:22 AM, Patient #37's bed alarm was going off, and staff found Patient #37 standing at the side of the bed. Patient #37 stated that she needed to stand up for a minute because her back and legs were hurting. She requested to sit in the chair, and staff asked her to sit on the side of the bed so that they could remove items from the chair. Patient #37 sat on the side of the bed, then slid herself onto the floor on her knees. She then turned herself to a sitting position on the floor and stated she could not get up. Two staff members assisted Patient #37 back to her bed.
- A care plan on 12/12/22 at 12:35 PM showed that on 12/12/22 at 12:00 PM, a staff member was assisting Patient #37 to the bedside commode (portable toilet that does not use running water). Patient #37 got to the side of the bed without assistance, and attempted to stand up. When she stood up, her legs "gave out." She stated that it felt like her legs were numb. Patient #37 was assisted back to her bed by staff, the bed alarm was turned on, and her call light was within reach.
- On 12/12/22 at 6:16 PM, her HDS score was a 12, which placed her at a moderate risk for falling, but fall risk per nursing judgement showed Patient #37 was a high fall risk. Moderate fall risk precautions were documented as a yellow bracelet, yellow non-skid slippers, fall precaution room signage, bed alarm and/or chair alarm. Nursing documentation showed the need for two staff to assist with mobility.

Review of the medical record for Patient #38 showed the following:
- She was a 60-year-old female admitted on 12/12/22 with a complaint of chest pain.
- She had been up and around on her own and was a low fall risk.
- She sat on the edge of the bed, leaned too far forward, and fell and hit her head on the corner of the visitor's chair in her room, on 12/12/22. The fall was witnessed by her significant other.
- The patient suffered a small laceration and abrasion on her forehead. A CT of the head was performed post fall and did not reveal any abnormalities.

All three current inpatients suffered a fall during their hospitalization.

Review of the medical record for Patient #23 showed the following:
- He was a 59-year-old male who presented to the ED on 10/30/22 at 9:46 AM, with a complaint of right leg pain.
- A nursing assessment completed on 10/30/22 at 10:21 PM, showed he was a high fall risk. Fall precaution interventions that were documented included familiarizing patient with environment, raising height of bed during transfers, non-skid socks and keeping the room clutter-free.
- A nursing assessment completed on 10/31/22 at 9:47 PM showed Patient #23 was a high fall risk, with fall precaution interventions of familiarizing patient with environment, locking the wheels on the bed and chair and non-skid socks.
- A flow sheet on 10/30/22 at 10:21 PM showed the patient's fall risk as moderate. An addendum to the 10/31/22 9:47 PM assessment was entered on 11/01/22 at 5:21 AM which showed that the patient refused to wear non-grip socks.
- A nursing note entered on 11/01/22 at 7:10 PM showed that at 3:36 AM, staff heard Patient #23's bed alarm, entered his room and found him lying on the floor. Blood was noted near Patient #23's head and a rapid response (a changing situation that requires more staff to address the current needs of the patient) was called at 3:37 AM. Patient #23 was not breathing, A code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was called at 3:38 AM. Patient #23 was pronounced dead at 4:00 AM.

Review of the medical record for Patient #35 dated 11/08/22 through 11/22/22, showed the following:
- He was a 70-year-old male who presented to the ED on 11/08/22 at 10:33 AM, via ambulance, with a complaint of a rash.
- Patient #35's inpatient diagnosis included altered mental status (AMS, mental functioning ranging from slight confusion to coma), human immunodeficiency virus (HIV, virus that attacks the cells that help the body fight infection), herpes zoster (shingles), blindness, confusion and sepsis (life threatening condition when the body's response to infection injures its own tissues and organs).
- He was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) on 11/08/22 at approximately 4:00 PM.
- On 11/12/22 at 2:35 AM, Physician documentation showed that Patient #35 fell out of bed, he was assessed at the bedside and x-rays (test that creates pictures of the structures inside the body-particularly bones) were ordered. Results of the x-ray showed a fracture to the left hip.
- On 11/12/22 at 9:00 AM, Nursing documentation showed that Patient #35 attempted to get up and fell. When staff found Patient #35 he was lying on his left side and reported left leg pain, specifically his left hip and knee. Patient #35 reported to staff that he "was trying to get to the children." He had been having visual hallucinations (seeing or hearing things which are not there) throughout the night, had been restless, attempted to get out of his bed and refused to keep his monitoring in place. Prior to his fall a bed alarm was in place, his call light was within reach and a fall sign was in place.
- On 11/12/22 at 5:06 PM, Physician documentation showed that Patient #35 underwent an open reduction internal fixation (ORIF, surgery to fix severely broken bones) of a left intertrochanteric (IT, bone at the top of the top leg bone) hip fracture acquired from his fall.
- Patient #35 was discharged to his home with home health on 11/22/22.

Review of the hospital's document titled, "Mercy Safety Event Review Approval Form," dated 11/12/22, showed the following:
- On 11/12/22 at 2:45 AM, nursing staff found Patient #35 in his room, on the floor, naked and laying in feces approximately three feet from his bed.
- Patient #35 was awake, responsive and stated that he was getting out of bed to "feed the kids" and his legs gave out and he fell to the ground.
- Patient #35 complained of pain in his left knee and hip which he rated a nine of 10 on a one to 10 pain scale.
- Patient #35 was assisted to his bed by nursing staff and evaluated by the nurse practitioner who ordered an x-ray.
- Prior to his fall, Patient #35's HDS score was a 26, which placed him at a high risk for falling.
- Patient #35's fall resulted in a left hip fracture that required a surgical repair.
- Patient #35 had AMS prior to his fall.
- Prior to the fall, interventions to prevent falls included a yellow arm band, his call light and personal items were within his reach and he had a bed alarm. The bed alarm did not sound and staff did not know why it had not alarmed.
- New actions to prevent further falls included a bed alarm and nurse rounding.
- Additional event details stated that Patient #35 had been experiencing auditory and visual hallucinations throughout the night, but was able to be re-directed by staff when attempting to stand independent of staff. Staff had frequently responded to Patient #35's bed alarm going off prior to his fall.
- Hospital findings determined that Patient #35 could have been evaluated for a virtual sitter (a person assigned to continuously monitor a patient using a portable video camera) to prevent his fall.

Both discharged patients suffered a fall during their hospitalization which caused injuries that resulted in the need for additional medical treatment.

Observation on 12/19/22 at 1:00 PM on the seventh floor, showed no fall risk sign for Patient #37, who was documented as a high fall risk and had two previous falls documented for this hospitalization.

Observation on 12/19/22 at 1:00 PM, on the fifth floor, showed no fall risk sign and no yellow bracelet for Patient #39, who was documented as a moderate fall risk.

Observation on 12/19/22 at 12:49 PM, on the fifth floor, showed no fall risk sign and no yellow bracelet for Patient #40, who was documented as a high fall risk.

Observation on 12/19/22 at 1:15 PM, on the fifth floor, showed no fall risk sign for Patient #41, who was documented as a high fall risk.

Observation on 12/19/22 at 12:40 PM on the seventh floor, showed no fall risk sign for Patient #42, who was documented as a high fall risk.

Observation on 12/19/22 at 1:07 PM on the seventh floor, showed no fall risk sign for Patient #43, who was documented as a moderate fall risk.

Observation on 12/19/22 at 3:15 PM, on the sixth floor, showed that Patient #45 had the same fall interventions in place as Patient #46 and #47, but Patient #45 was at a low risk for falls.

Observation on 12/19/22 at 3:20 PM, on the sixth floor, showed no fall risk sign for Patient #46, who was documented as a high fall risk.

Observation on 12/19/22 at 3:30 PM, on the sixth floor, showed no fall risk sign for Patient #47, who was documented as a high fall risk.

During an interview on 12/19/22, Staff C, RN, Nurse Manager, stated that there were a lot of patient falls on the sixth floor.

During an interview on 12/19/22, Staff LL, LPN, stated that all patients on the sixth floor were considered a high fall risk. All patients received the same interventions whether they scored as a high or a low fall risk, and she treated them all the same.

During an interview on 12/19/22 at 1:15 PM, Staff XX, LPN, stated that he would expect to see a fall risk sign on the patient's door, a yellow bracelet on the patient's wrist, non-slip socks on the patient's feet, and the bed alarm should be on for patients who have a moderate or high fall risk.

During an interview on 12/19/22, Staff HH, RN, Nurse Manager, Fifth Floor, stated that:
- Every patient should be assessed for fall risk on admission and every eight hours. Nurses should relay this information in bedside report at each shift change.
- He would expect to see a fall risk sign on the patient's door, if the patient had a moderate or high fall risk documented.
- He was unable to identify patients who were at a moderate or high fall risk on any current reports from the EHR.

During an interview on 12/19/22 at 1:17 PM, Staff ZZ, Patient Care Assistant, stated that she was not sure if she could leave a patient who had fallen to get help. She did not include a fall risk sign as a fall precaution.

During an interview on 12/19/22 at 1:32 PM, Staff AAA, RN, Float Pool, stated that there had been an increase in the number of falls over the past few weeks. She could not say if there were any trends within the increased falls and she had not been involved in any of the falls.

During an interview on 12/19/22 at 3:07 PM, Staff G, RN, Charge Nurse, stated that fall precautions included a fall risk sign, but she "had not seen any recently."

During an interview on 12/19/22 at 3:33 PM, Staff BBB, LPN, stated that patients could be identified as a fall risk by the fall risk score, calculated by the EHR, and by nursing judgement. If a patient was identified as a fall risk, whether by fall risk score or nursing judgement, a fall risk sign would be put in place.

During an interview on 12/19/22 at 4:24 PM, Staff M, CNO, stated that it was her expectation that if a patient was determined to be a high fall risk, whether by fall risk score or by nursing judgement, a fall risk sign would be placed on the patient's door so that any staff member answering a call light would know that the patient was at a high risk for falling.

Staff failed to follow their policy and provide protection from falls to current inpatients and this had the potential to result in falls and injury to all inpatients.

3. Review of the hospital's policy titled, "IV Care and Maintenance Policy," dated 06/04/21, directed staff to change IV dressings every seven days or as needed and label with date, time, and initials when changed. The policy also directed staff to remove any prehospital IV within 24 hours.

Observation on 12/12/22 at 3:00 PM, on the seventh floor, showed Patient #1's IV dressings on both hands were not dated, timed, or initialed.

Observation on 12/12/22 at 3:10 PM, on the seventh floor, showed Patient #2's IV dressings on her left wrist and left antecubital (AC, inner elbow) area were not dated, timed, or initialed.

Observation on 12/12/22 at 3:40 PM, on the seventh floor, showed Patient #3's IV dressing on her right chest was not dated, timed, or initialed.

Observation 12/12/22 at 2:45 PM, on the sixth floor, showed Patient #5's IV dressing on his right arm was not dated, timed, or initialed.

Observation 12/12/22 at 3:15 PM, on the sixth floor, showed Patient #7's IV dressing on his left arm was not dated, timed, or initialed.

Observation on 12/13/22 at 9:00 AM, on the third floor, showed Patient #10's IV dressing on her left upper arm was not dated, timed, or initialed.

Observation on 12/13/22 at 8:40 AM, on the third floor, showed Patient #11's IV dressing on her left forearm was not dated, timed, or initialed.

Observation on 12/13/22 at 8:25 AM, on the sixth floor, showed Patient #14's IV dressings on her right forearm and left AC area were not dated, time, or initialed.

Observation and subsequent medical record review on 12/13/22 at 9:20 AM, on the sixth floor, showed Patient #15's IV dressing on her right AC area was not dated, timed, or initialed. Review of Patient #15's medical record showed that the IV had been started by ambulance personnel on 12/11/22 at 8:15 AM.

Observation on 12/13/22 at 9:45 AM, on the sixth floor, showed Patient #16's IV dressing on her left hand was not dated, timed, or initialed.

Observation on 12/13/22 at 9:15 AM, on the seventh floor, showed Patient #18's IV dressing on his right AC area was not dated, timed, or initialed.

Observation on 12/13/22 at 10:15 AM, on the fifth floor, showed Patient #19's IV dressing on his right hand was not dated, timed, or initialed.

Observation on 12/13/22 at 10:30 AM, on the third floor, showed Patient #20's IV dressings on each forearm were not dated, timed, or initialed.

Observation on 12/13/22 at 10:35 AM, on the third floor, showed Patient #21's IV dressing on his right hand was not dated, timed, or initialed.

Observation on 12/13/22 at 11:10 AM, on the third floor, showed Patient #22's IV dressing on his left AC area was not dated, timed, or initialed.

During an interview on 12/13/22 at 8:35 AM, Staff KK, LPN, stated that she did not know if peripheral IV dressings were supposed to be dated, time and initialed.

During an interview on 12/12/22 at 3:30 PM, Staff H, RN, Clinical Educator, stated that all IV sites should be dated, timed, and initialed.

During an interview on 12/13/22 at 8:55 AM, Staff C, RN, Nurse Manager, stated that peripheral IV dressings were to be labeled with the date, time and initials of staff who initiated the IV. Staff C stated that IVs inserted before hospital admission were to be restarted within 24 hours of admission.

During an interview on 12/13/22 at 8:45 AM, Staff Q, RN, Nurse Manager, stated that when a nurse initiated an IV, the IV should be dated, timed, and initialed per the policy.

During an interview on 12/14/22 at 1:07 PM, Staff M, CNO, stated that she expected that all IV sites would be labeled with a date, time, and initials.



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