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Based on interview and review of medical records, facility policy, and evidence-based practice, the facility failed to ensure intravenous medications were administered in accordance with State law and approved medical staff policies and procedures. Assessments (i.e., proper functioning, complications, and removal) were not documented for 2 of 5 patients reviewed for peripheral intravenous catheter management. This failure placed patient #2 and patient #7 at risk for catheter-related bloodstream infections. .

Findings include:

Review of the Clinical Record of Patient #2 reflected documentation of peripheral IV placement dated 10/20/23 to Anterior Right Wrist reflected "placed: 10/20/2023 at 0624. Ultrasound guidance used to start IV: No. Extension set used: No. Placed under emergent conditions or outside of hospital: No. Size (Gauge) 20 G. Orientation: Anterior, Right."

Further review revealed skin assessments including assessment of the IV site; but no documentation related to the removal or discontinuation of the peripheral IV catheter.

During interview and review of patient #2's electronic clinical record, on the morning of 2/7/24, Staff #1, Director of Clinical Compliance and Accreditation, verified documentation of the discontinuation of Patient #2's peripheral IV catheter was not present. Staff #1 stated, "The expectation is that the nurse documents an assessment when a peripheral IV is discontinued. Here is what was not documented and should have been." Staff #1 handed surveyor a printed blank assessment tool.

Review of the unnamed facility printed assessment tool regarding peripheral IVs reflected the following data to be documented: Removal Date, Removal Time, Removal Reason, Line Removal Details, Provider Notified Immediately, Site Appearance, Adhesive Tape used.

During an interview on the morning of 2/7/24, Staff #8, Supervisor of Peri-anesthesia, stated, "The expectation of documentation when an IV is discontinued is the date and time it was removed, catheter tip was intact, bleeding was controlled, dressing placed on it."

Review of a Patient #7's Medication Administration Report (MAR) revealed that on 4/14/2023, in the hospital emergency department, Patient #7 was administered fluids and narcotic medication through intravenous route.

Further review of Patient #7's medical record revealed no documentation of ongoing site assessment or removal of the intravenous catheter prior to discharge from the emergency department on 4/14/2023.

An interview in the facility conference room on the afternoon of 2/7/2024, with Staff #2, Registered Nurse, Clinical Informaticist, revealed the intravenous catheter was placed by emergency medical services personnel. Staff #2 confirmed there was no assessment of the intravenous catheter and no notation regarding the removal of the intravenous catheter documented in Patient #7's emergency department record.

Review of the facility policy and procedure titled "Vascular Access Device (VAD) Management - (Adult), effective 06/13/2023, origination date: 10/01/2015, reflected in part: " ...VADs are maintained in accordance with evidence-based practice including insertion, evaluation, maintenance and removal. Practices are implemented to reduce the risk of Catheter-Related Bloodstream Infections including but not limited to Central-Line Associated Bloodstream Infections (CLABSI) ..."

According to The American Journal of Nursing article titled, "CE: Evidence-Based Practice for Peripheral Intravenous Catheter Management" (found at: https://journals.lww.com/ajnonline/Fulltext/2023/01000/CE__Evidence_Based_Practice_for_Peripheral.15.aspx), stated, " ... The greatest potential risk to the patient who has any intravascular catheter is the development of a serious and potentially fatal bloodstream infection ... Assessment begins with identifying the presence of a device by asking the patient if they have an IV catheter, checking the patient's extremities, and confirming that the PIVC has been noted in the patient's electronic health record (EHR). Always make sure PIVCs are properly documented (insertion date, time, site, gauge, reason for initial insertion, reason for continued use of the device, ongoing site assessment) so none are missed. Ensure that the PIVC is still necessary for treatment, still functioning, still tolerated by the patient, and still free from signs of complications or infection. If the PIVC has not been used in the past 24 hours or has no indications for use (medical therapy, planned procedure, hemodynamic instability), it should be removed. Leaving an unneeded PIVC in situ after hospital discharge has been attributed to negligence and lack of nursing assessment ...."