HospitalInspections.org

Based on record review, staff interviews, review of policy and procedures and review of patient (Pt) grievances the facility failed to:
Part I-Ensure 2 of 10 patients (Patient's 3 and 7) receiving intravenous (IV) (fluids/medication flowing into the vein via a tube or syringe) therapy received nursing assessments and interventions to treat infiltration (fluid leaking into the tissue at the site of the IV) of IV fluid/medication and documentation of assessments and interventions in accordance with the facility policy and procedures and;
Part II- Ensure the nursing staff in the Short Stay/Observation Unit failed to educate and ensure supervision of patient needs regarding the use of an inoperable side rail call light system resulting in 1 of 4 patients (Patient 2) in the Short Stay/Observation Unit (an 8 bed unit) being incontinent (uncontrolled urination) due to the inability to alert nursing staff of the need to urinate. The facility census was 103.

Findings are:

Part I
A. A review of the closed medical record for Patient 3 admitted 8/9/17 and discharged 8/14/17 following a lumbar fusion (lower back spine surgery) and decompressive laminectomy (removal of bone in the spinal column to release pressure on the spinal nerves) of L3/4 (Lumbar spinal discs 3 and 4) and L4/5 (Lumbar spinal discs 4 and 5). A review of the Infusion Site Therapy flow sheet showed that on 8/9/17 an IV was started in Pt 3's right forearm for surgery, following surgery the patient was brought to the floor with an IV of Lactated Ringers (LR-IV fluids) running at 125 cc/hr (cubic centimeters per hour) via an IV pump. An IV of Dilaudid (a strong IV pain medication) PCA (Patient Controlled Analgesia) was also running at a continuous rate of 0.2 mg /ml (milligram/milliliter) with 0.5 mg available q (every) hour as needed for pain via a PCA pump. On 8/10/17 at 1600 (4:00 PM) Registered Nurse (RN) M documented on the Infusion Site Therapy flow sheet that the IV was infusing in right forearm without signs of infiltration or phlebitis (inflammation of the vein); at 2006 (8:06 PM) RN N documented on the Infusion Site Therapy flow sheet that the IV was infusing in the left hand without signs of infiltration or phlebitis. The medical record lacked documentation of the reason the IV site was changed from the right forearm to the left hand.

A telephone interview with on 8/30/17 at 1:40 PM with RN M regarding the change in the IV site revealed, RN M recalled what happened, RN M stated, "it infiltrated". It was ok at 1600. Then about 1630 PM (4:30 PM) it was infiltrated. "It was what I would call a medium infiltrate, it was an obvious infiltration into the forearm, you could see it." RN M revealed that an attempt was made to restart the IV without success due to the patient had "bad veins", so RN M called the supervisor on duty for someone else to try and start it. "It was about 6-6:30 PM before it was restarted due to it took that long for someone to come up. It was someone from ER (emergency room) or OR (surgery) that started it, RN M was unsure of the nurses name." "I believe I gave (Pt 3) some Norco (pain pills) for pain during this time." Review of the medical record while on the telephone interview revealed that RN M administered 2 Norco 7.5/325 tablets at 1709 (5:09 PM) per mouth. When asked if the patient had eaten yet, RN M revealed that (Pt 3) had not eaten yet just ice chips and sips but that the patient told RN M that had passed a small amount of flatus (gas rectally). When asked RN M if that nurse that started the IV charted it somewhere, RN M stated, "Usually they don't chart it, they tell us and we chart it." RN M stated, "I guess I forgot to chart it."

Review of Pt 3's pain documentation showed that the goal for Pt 3 was a 5 level of pain on a scale of 1-10 with 10 being the worst. The graph of Pt 3's pain rating revealed to be a "6" on 8/10/17 at 8:00 AM, 12 noon and 4:00 PM while the patient was receiving pain medication via the PCA pump. The graph showed that on 8/10/17 Pt 3 rated the pain as a "10" consistently between just after 4:00 PM until 8/11/17 at 8:00 AM. RN M revealed in the interview on 8/30/17 at 1:40 PM that the IV and PCA pump was restarted at between 6-6:30 PM on 8/10/17. The medical record lacked documentation of a bolus (larger dose) of Dilaudid after the IV was restarted to regain pain control or any additional oral pain medication administered until 8/11/17 at 8:05 AM to assist with regaining pain control. The medical record lacked physician notification that the patient consistently rating pain a "10" for 16 hours.

Review of the Physician Progress Note dated 8/11/17 at 0841 (8:41 AM) revealed the entry, "Upset at nursing care - "its been horrible".

Review of the facility policy named "Periphiv" with the Policy Stat ID: 2921026 last revised 04/2016 revealed:
-Infiltration/leakage at insertion site; 1) Remove cannula when infiltration noted. 2) Replace cannula as appropriate. 3)Use Infiltration Scale to provide uniform standard for measuring the degree of infiltration. "Grade 0-no symptoms; Grade 1-skin blanched, edema <1 inch in any direction, cool to touch, with or without pain.; Grade 2-skin blanched, edema 1-6 inches in any direction, cool to touch, with or without pain; Grade 3- Skin blanched, translucent, gross edema > 6 inches in any direction, cool to touch, mild-moderate pain, possible 'numbness' per patient; Grade 4- skin blanched, translucent, skin tight, leaking, skin discolored, bruised, swollen, gross edema >6 inches in any direction, deep pitting tissue edema, circulatory impairment, moderate-sever pain, infiltration of any amount of blood products, irritant, or vesicant.
-Documentation; When IV cannula inserted or changed, included gauge, site and number of attempts.; When IV cannula removed, inspect integrity of cannula, note abnormal appearance.

Review of Pt 3's medical record lacked documentation of the discontinuation of the IV in the right forearm, an assessment of the infiltration site in the right forearm, and the description of the insertion of the IV in the left hand including the type and size of the IV used to start it and who started it. On 8/29/17 at 10:00 AM, RN J verified that the medical record lacked the documentation of the reason for the change in Pt 3's IV, documentation of the discontinuation of right forearm IV, documentation of the assessment of the right forearm infiltration or documentation of the insertion of the new IV in the left hand.

B. A review of the closed medical record for Patient 7 admitted 6/7/17 and discharged 6/9/17 from the Observation Unit following an incision and drainage of a right leg abscess. A review of the medical record nurses notes revealed:
-6/9/17 at 0555 (5:55 AM), "Periph (peripheral) IV in LFA (left forearm) infiltrated, mild redness with tenderness. Dc'd (discontinued) cath tip intact-dsg (dressing) applied. New IV 22 g (22 gauge- needle size) started on 1st try to RFA (right forearm). tol (tolerated) well. Vanco (vancomycin-antibiotic) infusing."
-6/9/17 at 0810 (8:10 AM), "Resting/sleeping in bed. (parent) at bedside. Vitals stable. IV fluids continue to infuse. Old IV (LFA) Ice pack to site to help w/discomfort (with discomfort)-night RN removed. Ace wrap to RLE (right lower extremity (leg)) CDI (clean, dry and intact). Waiting for MD (doctor) to see."
-6/9/17 at 1212 (12:12 PM), "Ready for home, dressing changed/packed to RLE. Taught (parent) how to do for home and sent w/supplies (with supplies). All d/c (discharge) paperwork went over w/pt (with patient) and (parent). Understands all info. IV DC'd."

An interview with the Director of the Observation Unit (RN A) on 8/29/17 at 2:15 PM revealed that RN A reviewed Pt 7's documentation related to the 6/9/17 infiltration of the Vancomycin. The documentation showed the Vancomycin 1 gram in 100 mls of Dextrose 5% solution was initiated on 6/9/17 at 0520 (5:20 AM). At about 6 AM the patient complained of burning, the IV site was red with tenderness. The IV was DC'd with the catheter tip intact and a dressing applied. A new IV was started. The day RN notes showed at 8:10 AM ice pack to old IV site due to discomfort. "Vancomycin not on our extravastation protocol." The Patient was sent home later that day.

Review of the facility policy named "Extravasation of Intravenous Fluids/Medications" with the Policy Stat ID: 3414742 last revised 04/2017 revealed:
POLICY:
-Definitions -1) Extravasation inadvertent leakage or infiltration of intravenous or intraarterial fluids into interstitial tissue. 2) Vesicant- any agent (medication) capable of causing a blister and/or tissue damage or causing local or extensive tissue necrosis (death) with or without ulceration. The irritants can result in pain at the IV site and along the vein and may or may not cause inflammation. Extravasation can result in tissue sloughing, pain, loss of mobility in the extremity and infection. The treatment for extravasation will vary depending on the antidote for the infiltrated medication and your facility policy.
-If an extravasation of an agent is recognized, notify the physician and the pharmacist.
-Antidotes and treatment of extravasation need to be initiated within an hour of discovery.
PROCEDURE:
-Management of Extravasation- a) Stop the infusion of the drug immediately. b) Stop any other IV solutions. c) Don appropriate PPE (personal protective equipment- gown/gloves). d) Disconnect the IV, leaving the needle in place... e)Attach syringe, attempt to aspirate the residual drug without placing pressure on the extravasated area, and then remove the needle. f) Notify the physician to initiate Extravasation order set or specific physician preferred orders and contact the Pharmacy Department. g) Obtain appropriate antidote from Pharmacy. h) Administer the antidote subcutaneously in a pincushion technique using a new 25-gauge or 27- gauge needle with each injection. i) Mark the boundary of extravasation with a marker. j) Elevate limb and avoid excessive pressure. k) Apply heat or cold packs as directed per "Extravasation Antidote Guidelines." l) Instruct patient to rest and elevate the site for 48 hours.
MISCELLANEOUS AGENTS- Vancomycin; ANTIDOTE- No specific antidote necessary; LOCAL CARE- Apply warm compress 20 minutes qid (4 times a day) x (by) 48 hours. Elevate extremity for 48 hours.

Review of the Extravasation Policy showed that Vancomycin was included under Miscellaneous agents. The medical record lacked documentation of following the extravasation policy and procedure following the incident of infiltration of the Vancomycin for Pt 7.

Review of the discharge instructions for Patient 7 lacked any care of the LFA infiltration site following the extravasation of the Vancomycin.

An interview with the Quality Director on 8/30/17 at 10:20 AM regarding the Vancomycin infiltration on 6/9/17 for Patient 7 revealed, "There was no IRIS (incident report) report done. There should have been a report due to it was an extravasation and has a protocol. We need to do some education."


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Part II

A. Record review of grievance files revealed Patient 2 filed a grievance via phone with the hospital on 8/7/17. The grievance notes that the patient told staff he/she had to urinate "badly" while in recovery post surgical procedure. The patient was offered a bedpan which was refused. The patient chose to wait until they got to their room about an hour later. The patient was then told to wait until the Blood Pressure was taken. The patient unable to wait any longer wet the bed. The patient stated he/she was "very embarrassed.". Later the patient needed to go to the bathroom again and pushed the nurse call button. There was no response for 30 minutes. The patient's daughter had to go find a nurse during which time the patient could not wait and wet the bed again. Record review revealed the patient was in the Observation Unit admitted post operatively on 8/2/17 and discharged 8/4/17.
B. Staff interview with RN A, the Director of the Observation Unit (OU) on 8/29/17 at 2:15 PM reviewed the grievance and felt nursing staff "met expectations." RN A stated there was no call light malfunction in the Observation Unit during the patient's stay. The OU is a small 8 bed unit with single rooms in an "L" shape around a central nurses station. RN A stated that the some of the beds have a nurses image for call light activation on the bed railing. This system was never hooked up in the OU. Instead patients have a call button on the bedside table and a call light string to pull which can also be used to call the nurse. Staff are to educate patients on admission to the call light system.
C. Observations in the OU on 8/30/17 at 4:00 PM with the Director of Nurses and Quality Director revealed that on the bedside tables in each room is a small approximately 3 inch square raised wood colored brown box. The box is affixed to the table and has a small push button in the center. When the patient pushes the button on the box a doorbell chime is heard at the desk but shuts off after 30 seconds. The patients room number shows in a digital display at the nurses call station at the desk. When near the end room of the L shaped unit the door bell chime was difficult to hear. The patients also have a bright orange string like chord they can pull to call the nurse. The orange chord activates a light above the patient's door and is audible in all areas of the unit.
D. Phone interview with Patient 2 on 8/30/17 at 10:15 AM revealed the patient used the call light by pushing the nurse symbol on the bed rail and it did not work. No one came until family went and got the nurse. The patient could not wait any longer and urinated in the bed. The patient confirmed he/she was not educated on using the box with the button or pulling the string to call a nurse on admission to the unit.
E. Observation of the OU on 8/31/17 at 8:50 AM with the Quality Director revealed there were 8 patients in the unit. Staff added length to the orange string/chord call light and added clips to make them more accessible to patients. The call boxes were removed. The nurse symbol on the bed rail was covered.