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Based on record review, interview, and policy review, the hospital failed to document intravenous therapy for patients receiving outpatient procedures. This affected eight (Patients #2, #3, #4, #6, #7, #8, #9, and #10) of ten patients reviewed. The hospital census was 138.

See A1081

Based on record review, interview, and policy review, the hospital failed to document intravenous therapy for patients receiving outpatient procedures. This affected eight (Patients #2, #3, #4, #6, #7, #8, #9, and #10) of ten patients reviewed. The hospital census was 138.

Findings include:

Review of the medical record for Patient #6 revealed an outpatient Computed Tomography (CT) scan was completed on 09/12/23.

Review of medical record for Patient #6 revealed she had outpatient CT Scan service date 09/12/23. The CT Scan with contrast was ordered for acute abdominal pain. The contrast, 75 milliliter of ISOVUE-370 at 76% solution, was given via an intravenous (IV) line once in imaging, per CT Scan technologist for one dose. There was no documentation for Patient #6 regarding the time the IV line was started, the location of the IV, the gauge of the IV used, the appearance of the IV site or any complications related to the IV line.

Review of the medical records for outpatient CT scans for Patients #2, #3, #4, #7, #8, #9, and #10 revealed no documentation regarding their IV line used for the procedure.

Review of the grievance log dated 09/12/23 revealed that Patient #6 had called on 10/03/23 to hospital imaging to report during her CT Scan on 09/12/23 the technologist hit a nerve while injecting contrast media. Patient #6 stated she was suffering with nerve pain and had discussed it with her physician and wanted to know what to do about it.

During interview on 11/20/23 at 10:41 A.M., Computer Tomography (CT) Technician #D stated staff had previously documented in the record when an IV was started on a patient. Staff were then told not to document as it would get mixed up in a patient with too many IV's.

During interview on 11/20/23 at 10:50 A.M., with CT Technician #A stated IV therapy is not documented on outpatients. The IV is only in for three minutes, then is removed.

During interview on 11/20/23 at 11:50 A.M., Manager of Radiology Services #E stated Patients #2, #3, #4, #6, #7, #8, #9, and #10 had no documentation regarding the IV site in their medical records..

Review of the hospital policy titled "Intravenous IV Therapy Policy and Procedure", dated 01/12/23, revealed the safe administration of intravenous therapy was responsible of nursing personnel associated with the initiation, administration, and monitoring of IV therapy. Peripheral IV site to be assessed every four hours. IV for CT or MRI power injections should be a 20 gauge or larger IV placed in the forearm or antecubital fossa, if unable to access forearm vessel.