HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure care of an intravenous (IV) line was provided by a licensed healthcare provider for 1 patient (#1) of 7 patients reviewed.

The findings included:

Medical record review revealed Patient #1 was admitted to the facility on 8/6/18 for a Right Hip Replacement and was discharged on 8/7/18.

Medical record review of a Pre-operative Nursing flowsheet revealed a #18 gauge IV was inserted into Patient #1's right forearm to administer IV fluids on 8/6/18 at 7:42 AM.

Interview with the Tower 3 Unit Nurse Manager on 8/20/18 at 2:30PM, in the conference room, revealed the facility received a complaint on 8/19/18 from Patient #1's wife alleging "...a CNA [certified nurse assistant] had disconnected the IV line when the patient needed to go to the bathroom...the IV line was bleeding...the CNA wrapped the IV site in the blanket...I talked to the night shift nurse...[named night shift nurse] said the patient [told night shift nurse] the CNA unhooked the IV when he was going to get up and when they got to the bathroom there was blood dripping on the floor...CNA wrapped the IV site in a blanket because it was bleeding..." Further interview confirmed the CNA disconnected the IV line and that was not within the CNA's scope of practice.

Telephone interview with Registered Nurse (RN) #1 on 8/20/18 at 2:55 PM revealed "...the CNA apparently unhooked the IV line...took the patient to the bathroom...there was blood on the IV site and in the floor and that is when she [CNA] wrapped the IV line in the towel...the CNA should not be disconnecting IV lines for any reason..."

Interview with RN #2 on 8/20/18 at 3:30 PM, in the conference room, revealed "...I spoke with the CNA the next morning and she said the patient wanted to go to the bathroom...the IV became disconnected...she [CNA #1] said there was blood and she took a saline syringe to clean it off and wrapped the IV site in a towel..."

Telephone interview with CNA #1 on 8/20/18 at 3:40 PM revealed the CNA went into the patient's room to take him to the bathroom. Further interview revealed "...the patient was upset over something. When I got him up, his IV was wrapped around the IV pole so I had to unwrap the tubing and disconnected the IV...when we got in the bathroom there was blood around the IV site and it was actively bleeding...I used a saline flush to clean the blood off the site and wrapped it in a towel...I could not leave the room because the patient was in the bathroom..."

Telephone interview with the Director of Nursing on 8/27/18 at 9:30 AM confirmed the CNA disconnected Patient #1's IV, which was not within the scope of practice for CNAs.