HospitalInspections.org

Based on a review of clinical records and facility documentation, the facility failed to have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care.

Findings were:

During a review of the clinical records for 10 patients (patients #1 - #10), findings were as follows:

-9 of the 10 records (patients #1 - #9) contained no documentation of the condition of the intravenous site following the discontinuation of the intravenous access.

-6 of the 10 records (patients #2, #3, #4, #5, #6 and #8) contained no daily documentation of the condition of the intravenous site for 48 hours following removal.

-1 of the 10 records (patient #7) contained no documentation that intravenous access had been discontinued prior to the patient's discharge. The record contained no documentation of a physician's order that patient #7 be discharged with intravenous access still in place.

-5 of the 10 records (patients #2, #3, #4, #5 and #8) indicated that the patient had fluids infusing through their intravenous access. Their clinical records contained no documentation of an intravenous site assessment at a minimum of every 4 hours.

Facility policy titled "Peripheral Intravenous Catheter-Inserting, Maintaining, and Discontinuing- Adults" stated, in part:
"Key Points-General

17. Monitor IV site, according to Peripheral IV Catheter Adult ATTACHMENT 'Frequency of IV Site Assessment.pdf'

18. Documented the condition utilizing the Peripheral IV Catheter Adult 'ATTACHMENT Phlebitis Infiltration Scales.pdf'

a. Complaints of pain at the IV insertion site require assessment for infiltration and/or phlebitis.
b. b. Any evidence of infiltration and/or phlebitis will require that the IV catheter be discontinued immediately ...

Procedure 3- Maintaining Peripheral Intravenous Catheters ...

2. Inspect site frequently during continuous infusions for evidence of complications, i.e. redness, tenderness, edema, or drainage ...

Procedure 4- Discontinuing Peripheral Intravenous Catheters ...
Documentation ...
" Patient care record-used to document the insertion, maintenance, and discontinuation of peripheral intravenous catheter.
Instructions
1. Record the date and time of initiation, maintenance and discontinuation of IV medications, IV flushes, and IV solutions as appropriate ...
2. ...
3. Document the discontinuation of a peripheral intravenous catheter in designated areas on the patient care record.

c. Note the date, time, and condition of site following discontinuation.

4. Document the assessment of previous IV sites, after IVs are removed at least daily for 48 hours.

Facility based attachment titled, "Frequency of IV Site Assessment When Fluids Are Infusing" stated, in part:
"Patient: Patients who are alert and oriented and can notify the nurse of signs of IV problems
Frequency: At least every 4 hours
[Under "Patient" heading] Critically ill patients
[Under "Frequency" heading] At least every 1 to 2 hours
[Under "Patient" heading] Adult patients with cognitive/sensory deficit
[Under "Frequency" heading] At least every 1 to 2 hours
[Under "Patient" heading] Adult patient receiving sedative-type meds
[Under "Frequency" heading] At least every 1 to 2 hours"

The above was confirmed in an interview with the Chief Nursing Officer and other administrative staff the afternoon of 11-29-17.

Based on a review of clinical records, the facility failed to document an updated examination of the patient, including any changes in the patient's condition, when the medical history and physical examination are completed within 30 days before admission or registration.

Findings were:

During a review of clinical records for 10 patients (patients #1 - #10), 1 of 10 records (patient #1) did not contain an updated examination of the patient, including any changes in the patient's condition. The medical history and physical examination had been completed on 8-29-17. The physician saw the patient the morning of surgery, but did not indicate whether or not there were any changes to the history and physical at that time.

Facility policy titled "Assessing Reassessing a Patient" stated, in part:
"Group II: For procedure- "Assessing Reassessing a Patient", groups caring for patients with an anticipated stay of 23 hours or less (including patients who may undergo procedures that place them at risk for loss of protective reflexes, i.e. day surgery, endoscopy, special procedures, observation are to meet the following requirements as appropriate to the patient population and care setting ...
Assessment & Screenings:
1. The patient receives a medical history and physical examination performed by a member of the Seton medical associates or Seton credentialed Advance Practice Registered Nurse or Physician Assistant no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or procedure requiring anesthesia services. For medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any changes in the patient's medical condition is completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services ..."

The above was confirmed in an interview with the Chief Nursing Officer and other administrative staff the afternoon of 11-29-17.