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Based on record review, interview and policy review, the facility failed to allow two patients (Patient #1 and #8) to exercise their rights related to intravenous (IV) lines. The facility's census was 433.

See A129

Based on record review, interview and policy review, the facility failed to allow two patients (Patient #1 and #8) to exercise their rights related to intravenous (IV) lines. The facility's census was 433.

Findings include:

1. Patient #1 was admitted to the hospital on 04/02/24 with abdominal pain and diarrhea. She was found to have a partially occluded thrombus in the superior mesenteric vein. She was ordered heparin (blood thinner) on 04/02/24 and had an intravenous (IV) catheter placed in the left forearm on 04/02/24 at 4:45 AM in the emergency department. She was then transferred to the fourth floor of the hospital. Patient #1 then had another IV site placed on 04/03/24 at 3:52 PM. There was an order to discontinue heparin on 04/03/24 at 4:30 PM. Both of Patient #1's IV sites were removed on 04/04/24 at 12:29 PM.

Staff M and Staff V were interviewed on 05/08/24 at 9:00 AM. They reported Patient #1 complained that the student nurse just entered her room and did not ask her for permission to have a student nurse care for her. Patient #1 also reported that another nurse came in and reported that she needed another IV site due to the heparin needing its own site. Patient #1 reported to the nurse that she wanted the nurse to check with the physician first because he was going to discontinue her heparin. The nurse left the room and the next thing she knew the student was in the room putting in another IV site. Staff J reported that she immediately called the nurse manager and informed her of the complaint while Patient #1 was still in the hospital. She reported she then informed all the appropriate managers including the nursing school liaison and they investigated. She sent the response letter with an apology for her experience.

During interview on 05/08/24 at 10:01 AM, Staff J reported she had a student with her who was working her last four-hour shift of her practicum. Staff J reported that the student nurse and the LPN were assigned to Patient #1 who both had the same name. She had requested the LPN go into her room and assess whether the heparin was running into its own line. The LPN reported that the heparin was running into the line with the primary IV fluids and antibiotics running into it. Staff J reported that the facility does not have a policy on heparin running into its own line, and everything Patient #1 was receiving was compatible, but she prefers per her own professional judgement that heparin run into its own line. She reported she explained that to Patient #1 and Patient #1 expressed concerns that she would like her physician contacted first because he had spoken about discontinuing her IV heparin and starting her on oral anticoagulation due to her now tolerating foods. Staff J reported she then exited the room and paged the physician. Twenty minutes later she returned to Patient #1's room and observed the LPN placing an IV into Patient #1's arm and the physician had not called back yet. Staff J confirmed Patient #1 was extremely upset. The physician called back and did switch Patient #1 from IV heparin to oral anticoagulation one hour after the new IV site was inserted. She reported Patient #1 then called the operator to complain and was notified by her nurse manager that Patient #1 complained. She reported that she did go into Patient #1's room and listened to her grievances and apologized for her care and Patient #1 did allow her to take care of her the rest of the evening until 3:00 A.M. Staff J reported no other concerns with her care the rest of the evening.

2. Patient #8 was admitted to the emergency department on 12/02/23 and was discharged on 12/03/24. Patient #8 went to the emergency department with complaints of blurred vision for more than one week. Patient #8 had not had her blood pressure medications in two to three months due to being new to the area and not establishing care with a physician. Patient #8 returned to the emergency department on 01/02/24 with left and right arm pain. She was discharged from the emergency department on 01/03/24 with a diagnosis of superficial thrombophlebitis. Patient #8 was given discharge instructions to follow up with a physician.

Patient #8 was interviewed on 05/07/24 at 10:19 AM. Patient #8 reported she screamed and cried the night of 12/02/23 to have the staff remove the left arm IV site and staff would not listen to her. Patient #8 stated the facility's staff even had an ultrasound technician come into her room and informed the staff her IV was not in place.

During an interview on 05/08/24 at 8:37 AM, Staff F reported Patient #8 informed Staff F that the IV site hurt so Staff F verified it with an ultrasound machine, flushed the site with good blood return, and informed Patient #8 that the IV was in place and working properly. Staff F reported that Patient #8 never asked or demanded to have her IV site removed.

Staff I was interviewed on 05/08/24 at 9:47 AM. Staff I stated that Staff F reported to Staff I that Patient #8 was complaining of the IV site hurting and Staff F had assessed it, but Patient #8 was still complaining. Staff I then went to assess the IV site himself. Staff I stated he flushed the IV site and it flushed easily and had good blood return. Staff I also reported that he used the ultrasound machine to verify the placement and it showed the IV catheter in the vein. Staff I offered a new IV site to Patient #8 and at first, Patient #8 refused but eventually did receive one. Staff I reported Patient #8 was not asking to have the IV site removed she was just complaining it hurt.

Staff T was interviewed on 05/28/23 at 3:12 PM. Staff T reported Patient #8 had Patient #8's IV site placed in the pit (up front) area of the emergency department. "When she came back to my room, she had multiple complaints about it". Staff T and a paramedic checked it, and it was still working. Staff I looked at it and determined it was patent. Patient #8 "said that it hurt" and was concerned because nobody had ever placed an IV in that location before. The IV was in her upper arm, above the antecubital. Staff T was unable to recall if the IV was in the right or left arm. Staff T reported Staff T flushed the IV and it had no problems. "It was pulling back blood". Staff T reported the IV site "was hurting" Patient #8. "When I flushed it, she was acting as if she was in agony, she was constantly touching at it". Staff T reported Patient #8 was always very vocal, she never stopped even when there was nothing going through the IV. "I did not document the issues with the IV, I let my physician know". Staff T stated Patient #8 never asked Staff T to remove the IV site. Staff T reported Patient #8 "said it hurt, and she was concerned that she never saw an IV placed there before". "I did not remove the IV. Had she asked me to remove the IV, I would have removed the access". Staff T stated the facility wouldn't give up IV access until another IV site was established, unless the site was infiltrated.

The facility's Patient Right's and Responsibilities policy (2.2, Revision 10/18/21) stated:

D. Standard: Exercise of Rights

2. A patient or his/her representative has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment.

The facility's Intravenous (IV) Peripheral Catheter Site Inspection, Care and Rotation policy (4:4, Revision Date: 04/28/21) stated, in part:::

IV. Procedure:

B. Site inspection, connection, and pump rate verification

4. Explain procedure to patient
5. Inspect site through transparent semipermeable dressing
a. Do not remove dressing unless IV is rotated, if excessive drainage or moisture is noted, or if integrity of the dressing is compromised
b. Transparent semi-permeable dressings should be changed every 7 days
c. Gauze dressings should be changed every 48 hours Peripheral Intravenous Catheter Insertion and Dressing Change
6. Inspect and palpate insertion site for infusion related signs and symptoms such as:
a. Discoloration (blanching/erythema)
b. Disruption of sensation (pain, tenderness, numbness)
c. Edema (pitting, nonpitting)
d. Localized swelling
e. Exudate
1. Consider obtaining an order for cultures
2. Contact licensed independent practitioner (LP) for an order
f. Increase in skin and/or basal temperature
g. Pain and/or discomfort at the IV site
7. If there is evidence of complication or impending complication, remove the IV and notify LP (licensed practitioner) as indicated.

Based on record review, interview and policy review, the facility failed to document intravenous (IV) site condition assessments for three (Patients #8, #16 and #17) patients. The facility's census was 433.

See A395

Based on record review, interview and policy review, the facility failed to document intravenous (IV) site condition assessments for three (Patients #8, #16 and #17) patients. The facility's census was 433.

Findings include:

1. Patient #17 was interviewed on 05/23/24 at 8:24 AM. Patient #17's right arm IV site, located in the antecubital fossa (AC), was observed with circular bruising, approximately the size of a golf-ball. Patient #17 was questioned as to if the IV site was causing any pain. Patient #17 reported the right arm IV site was painful and that Patient #17 had reported the pain to a nurse who had flushed the site earlier. Patient #17 reported the site burned for 30 minutes after the nurse flushed the site. Nursing staff discontinued Patient #17's IV site after the observation. The medical record for Patient #17 contained documentation stating the right arm IV site was discontinued on 05/23/24 at 9:00 AM. The Removal Reason was listed as "Site Change".

The medical record did not contain documentation regarding the patient 's reported pain or regarding the bruising at the IV site.

The findings were shared with Staff CC on 05/23/24 at 8:24 AM, at the time of the observation, and confirmed.

2. Patient #8 was admitted to the emergency department on 12/02/23 and was discharged on 12/03/24. Patient #8 went to the emergency department for blurred vision for more than one week. She had not had her blood pressure medications in two to three months due to being new to the area and not establishing with a physician.

Patient #8 was interviewed on 05/07/24 at 10:19 AM. Patient #8 reported she screamed and cried the night of 12/02/23 to have the staff remove her left arm IV site and they would not listen to her. Patient #8 stated they even had an ultrasound technician come into her room and informed the staff her IV was not in place.

On 05/08/24 at 8:37 AM, Staff F reported Patient #8 informed Staff F that the IV site hurt so Staff F verified it with an ultrasound machine, flushed the site with good blood return, and informed Patient #8 that the IV was in place and working properly. Staff F reported that Patient #8 never asked or demanded to have her IV site removed.

Staff I was interviewed on 05/08/24 at 9:47 AM. Staff I that Staff F reported to Staff I that Patient #8 was complaining of the IV site hurting and Staff F had assessed it, but Patient #8 was still complaining. Staff I then went to assess the IV site, himself. Staff I stated he flushed the IV site and it flushed easily and had good blood return. Staff I also reported that he used the ultrasound machine to verify the placement and it showed the IV catheter in the vein. Staff I offered a new IV site to Patient #8 and at first, Patient #8 refused but eventually did receive one. Staff I reported Patient #8 was not asking to have the IV site removed she was just complaining it hurt.

Staff T was interviewed on 05/28/23 at 3:12 PM. Staff T reported Patient #8 had Patient #8's IV site placed in the pit (up front) area of the emergency department. "When she came back to my room, she had multiple complaints about it". Staff T and a paramedic checked it, and it was still working. Staff I looked at it and determined it was patent. Patient #8 "said that it hurt" and was concerned because nobody had ever placed an IV in that location before. The IV was in her upper arm, above the antecubital. Staff T was unable to recall if the IV was in the right or left arm. Staff T reported Staff T flushed the IV and it had no problems. "It was pulling back blood". Staff T reported the IV site "was hurting" Patient #8. "When I flushed it, she was acting as if she was in agony, she was constantly touching at it". Staff T reported Patient #8 was always very vocal, she never stopped even when there was nothing going through the IV. "I did not document the issues with the IV, I let my physician know". Staff T stated Patient #8 never asked Staff T to remove the IV site. Staff T reported Patient #8 "said it hurt, and she was concerned that she never saw an IV placed there before". "I did not remove the IV. Had she asked me to remove the IV, I would have removed the access". Staff T stated the facility wouldn't give up IV access until another IV site was established, unless the site was infiltrated.

The medical record for Patient #8 contained documentation by Staff S on 12/03/23 at 3:44 AM stating Patient #8 was complaining of pain of 8 in bilateral arms.

The medical record of Patient #8 contained the following IV (intravenous) documentation:

12/02/23 9:21 AM - Upper arm Left - ultrasound peripheral IV start. 18 gauge. Dressing clean, dry and intact. Flushes easily. No complications. Number of attempts = 1.

12/02/23 10:00 AM - Upper arm Left - ultrasound peripheral IV start. 18 gauge. Dressing clean, dry and intact. Flushes easily, 10 ml normal saline flush, good blood return. No complications. PRN (as needed) Adaptor

12/03/23 1:00 AM - Right Antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor.
- Upper arm Left - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor.

12/03/23 3:44 AM - Right Antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor.

12/03/23 9:35 AM - Right antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor.

12/03/23 4:37 PM - Right Antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor.

The medical record did not contain documentation of Patient #8's pain at the IV site.

3. On 05/22/24 at 9:18 PM, the medical record of Patient #16 contained documentation stating a peripheral IV in the right hand (inserted on 05/20/24) was discontinued and the site was changed. A new IV site was started on Patient #16 on 05/22/24 at 10:01 PM in the left hand. The medical record did not contain the condition of the site at the time of removal.

Per interview with Staff CC on 05/23/24 at 2:47 PM, staff are able to document the following under IV site condition in the electronic medical record: No complication, Blanched, Bleeding, Blistered, Circulatory Impairment, Cool to touch, Crepitus, Drainage present, Ecchymotic, Edema, Erythema, Hematoma, Hot to touch, Infiltrated with non-irritant, Infiltrated with blood, irritant or vesicant, Numbness, Pain, Red streaks, Tight, leaking, Translucent.

The facility's Intravenous (IV) Peripheral Catheter Site Inspection, Care and Rotation policy (4:4, Revision Date: 04/28/21) stated, in part:

IV. Procedure:
A. An RN (registered nurse) will assess and document the IV site at least every 4 hours
B. Site inspection, connection, and pump rate verification

6. Inspect and palpate insertion site for infusion related signs and symptoms such as:
a. Discoloration (blanching/erythema)
b. Disruption of sensation (pain, tenderness, numbness)
c. Edema (pitting, nonpitting)
d. Localized swelling
e. Exudate
1. Consider obtaining an order for cultures
2. Contact licensed independent practitioner (LP) for an order
f. Increase in skin and/or basal temperature
g. Pain and/or discomfort at the IV site

7. If there is evidence of complication or impending complication, remove the IV and notify LP (licensed practitioner) as indicated

9. Remove gloves and perform hand hygiene

10. Document site assessment in the medical record including but not limited to:

Documentation in the Electronic Medical Record Center Electronic Medical Record (EMR) Downtime Procedure
a. Location of the IV
b. Angiocath size
c. Fluid infusing
d. Site appearance
F. IV Phlebitis
1. Can occur up to 48 hours post catheter removal
2. Inspect insertion site for signs of tenderness, redness, warmth, edema, pain, inflammation, and/or vein induration
3. Swelling with a feeling of warmth at the site is the best indicator of phlebitis
4. Consider type of solution and/or medication infusing into affected area
5. Remove IV catheter if phlebitis is present
6. If an infection is suspected, obtain an order from the LP for culture prior to removal
7. Notify LP regarding any phlebitis
8. Apply a cold compress to site initially, followed by a warm compress
9. Elevate extremity
10. Document in patient's medical record
11. A void use of the affected extremity if possible
12. Document patient education as indicated
13. Continue to monitor site until resolution of phlebitis

G. IV Removal
1. Verify LP order
2. Perform hand hygiene
3. Verify patient's identity
4. Don clean gloves
5. Explain procedure to patient
6. Discontinue administration of all infusions prior to catheter removal
7. Remove dressing from catheter insertion site
8. Inspect catheter skin junction site
9. Disinfect catheter junction site with alcohol wipes to reduce risk of infection
10. Place a gauze pad over insertion site
11 . Using gentle, even pressure, slowly retract catheter from the site while holding site with gauze
a. If resistance or complications occurs, discontinue removal and notify LP immediately
12. Assess integrity of the removed catheter. Verify that the entire catheter has been removed
a. Notify LP if catheter is not intact
13. Apply pressure to the exit site for at least 30 seconds or until hemostasis is achieved
14. Apply a new gauze pad or Band-Aid to exit site
15. Remove gloves
16. Perform hand hygiene
17. Document in the medical record.
a. Patient education as indicated
b. Catheter removal
c. Condition of site

H. Rotation of IV site
1. Peripheral intravenous catheters will be rotated when clinically indicated
a. Assess site and surrounding area, by palpation and inspection, including catheter pathway, for integrity of skin, dressing, and securement device
b. Identify signs of complications, evidence of dislodgement, redness, tenderness, swelling, infiltration, induration, body temperature elevation, drainage or pain.