HospitalInspections.org

Based on medical record (MR) review, document review and interview, in one (1) of three (3) MRs, the nursing staff failed to ensure a patient's intravenous (IV) access was discontinued prior to discharge.

Findings:

The facility policy and procedure (P&P) titled, "Peripheral IV Catheters including Extended Dwell Catheters, Insertion, Maintenance, and Removal - Adult," last reviewed on 3/30/2020, stated, "Documentation regarding insertion or removal of a peripheral IV must be entered in the patient's medical record."

Review of Patient #10's MR identified this patient presented to the Emergency Department (ED) via ambulance with complaints of right eye pain and swelling, fevers, intermittent dizziness and blurry vision for three (3) days. Patient #10 was transferred to this facility on 4/8/2022 from an affiliated hospital for an Ophthalmology Consult.

Per the Nursing Triage Note dated 4/9/2022 at 01:19 AM, Patient #10 had a #22-gauge IV Angiocatheter (Angiocath) that was placed in the Left Arm A/C (antecubital space) by the transferring hospital, and flushed without difficulty.

The presence of the IV was also documented in the Nursing Flow Sheet dated 4/9/2022 at 01:43AM, which noted that the peripheral Angiocath was in place prior to hospital arrival, flushed without difficulty with 0.9% sodium chloride, and that dressing was dry and intact. No documentation that this IV access was removed prior to the patient's discharge was found.

This finding was confirmed with Staff F (Nurse Manager) on 7/7/2022 at 12:20 PM.