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Based on document review and interview nursing staff failed to ensure an assessment and reassessment was completed before discharging Patient #1 (1 of 1 patient's patient medical records reviewed). Failure to complete the assessment resulted in Patient #1 being discharged with an intravenous (IV) catheter left in place (a small plastic tube placed into a vein and used to administer medications, fluids, and blood) in his left forearm.

Findings:

A review of Patient #1's chart was conducted on 1/06/2025 after 12:00 PM with Registered Nurse (RN) Staff #2. A review of the nursing documentation revealed RN Staff #11 inserted an IV in the left forearm on 12/11/2024 at 3:25 PM and RN Staff #10 removed the IV in the left forearm on 12/12/2024 at 1:08 PM.
Further review revealed RN Staff #12 documented on 12/12/2024 at 1:08 PM that "No biobutton or telemetry. No IVs to remove ..." and RN Staff #12 transported Patient #1 by wheelchair and placed him in a taxi on 12/12/2024 at 3:23 PM to be discharged home.

A grievance filed by Patient #1's mother was reviewed on 1/06/2025 after 12:00 PM with RN staff #2. The grievance investigation revealed that Patient #1's mother called to report that an IV had been left in her son's arm. The patients mother stated she called and spoke with the house supervisor and the charge nurse. Patient #1's mother reported that the charge nurse stated, "It has been documented that his IVs were removed" and repeatedly said, "What do you want me to do?" The mother then called and requested to speak to administration and was told to "call 911 if you can't remove it". Who did she speak with in administration and who told her to call 911. The mother called 911 and the IV was removed from his arm.


A review of the documentation provided by the ambulance service revealed that Unit 954 was called to Patient #1's residence on 12/12/2024 at 5:34 PM. The documentation was as follows, "EMS responded to call and arrived on scene to a female standing in the driveway, upon Ems exiting the ambulance the female stated that a stretcher was not needed and that the sick person her male middle age son was only needing to have iv's removed from his arm. Ems entered residence and found the male pt sitting on the couch who refused any kind of treatment and transport to hospital, he only wanted the IV in his left arm removed, mother of pt stated that he was just discharged from hospital in Athens and iv was left in his arm. 954 medic removed the iv safely and properly disposed of the iv, a 4x4 and tape was placed on the iv site. Pt refused any other treatment and refusal form was signed by pt and witnessed by mother by her signature. Ems was cleared of call".


An interview was conducted with RN staff #2 on 1/06/2025 after 12:00 PM. RN Staff #2 was asked if she spoke to the nursing staff during the investigation of the grievance. RN Staff #2 confirmed she spoke with the RNs involved with the care of Patient #1. RN Staff #2 confirmed the IV was not removed before discharge. RN Staff #2 confirmed there was no documentation regarding the conversation she had with the nurse and no re-education was given to the nursing staff on assessing patients before discharge.