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Based on medical record (MR) review, observation, document review, and interview, in one of four (4) patients, nursing staff did not ensure intravenous (IV) tubing was properly dated and timed, as per facility policy.

Findings:

Review of Patient #3's MR revealed that this patient was admitted to the Cardiac Intensive Care Unit (CCU) for invasive hemodynamic monitoring (use of sensors and catheters to monitor a patient's heart function). A midline catheter (a long IV catheter inserted into a vein in the upper arm) was placed on 10/24/2025, and a central line catheter (a thin, flexible tube inserted into a large vein in the chest, neck, or groin and advanced into the large vein that carries blood to the heart) was placed on 10/27/2025. On 10/29/2025 at 1:23PM, a physician order was placed to change Patient #3's IV tubing every four (4) days. On 10/30/2025 at 5:00AM, the patient's IV tubing was changed.

During a tour of the CCU on 10/30/2025 at 12:00PM, Patient #3's IV tubings were found undated and untimed to help indicate when the tubing was to be changed. Tubing #1 had a pink label with the words "Change Sunday." Tubing #s 2, 3, and 4 had brown labels with the words, "Change Friday." All four (4) labels had lines designated for the date and time that were blank.

Review of the facility's policy and procedure (P&P) titled, "Standards of Nursing Practice for Care of The Adult Patient with Midline Catheter," revised 08/2022, indicated: "Note the date and time labeled on the dressing, all hanging IV solutions, and administration sets."

This finding was shared with Staff I (Administrator) and Staff J (Administrator) on 10/30/2025 at 12:20 PM.

During interview of Staff K (Nurse) on 10/30/2025 at 3:19 PM, Staff K stated that they do not always write the date on the tubing.

During interview of Staff I (Administrator) on 10/30/2025 at 3:51 PM, Staff I confirmed these findings and stated that they were unaware of a policy guiding staff to date/time IV tubing.