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27100 CHARDON ROAD

RICHMOND HEIGHTS, OH 44143

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on medical record review, policy review and staff interview, the facility failed to ensure a registered nurse evaluated the care of one of three sampled patients who received intravenous care (Patient #5). The facility had a current census of 60 patients (30 patients at Richmond Heights location and 30 patients at Bedford location).

Findings include:

1. On 10/16/19 at 4:15 PM, review of the policy titled, Peripheral Intravenous Catheter (PIV) Insertion, Maintenance, Blood Collection & Removal-Adult, revised June 2018 revealed "1.8. Provider order required to start a PIC. 1.8.1. Exceptions: emergency situation or restarts." "13.1. Insertion documentation 1.3.1. Date of insertion on the dressing 13.3.2. Medical Record 13.3.2.1. Date Inserted 13.3.2.2. Location 13.3.3.3. Gauge and length 13.3.2.4. Number of attempts 13.3.2.5. Patient tolerance"

"14. RN assesses and monitors the condition of PIV during all patient encounters. 14.1. Assessment consists of palpation through the dressing to discern tenderness and inspection of the insertion site if a transparent dressing is in use." "14.2. PIV documentation is completed at least two times per 24 hours approximately 12 hours apart and/or as appropriate for patient condition or per unit standard. Documentation consists of: 14.2.1 Condition of dressing
14.2.2. Condition of insertion site 14.2.2.1 Phlebitis Scale (Attachment C) 14.2.2.2 Infiltration Scale (Attachment D) 14.2.2.3 Presence of drainage 14.2.3 Patency 14.2.4 IV pump settings if applicable."

"17. The RN assesses the continued need for the PIV and removes the PIV when the patient develops signs of infiltration, phlebitis, infection, or when the integrity and patency of the existing PIV is absent."

Review of the Policy titled, GM-68-Medical Record Content, revised 02/19 revealed the following: "2. An in-patient record includes the following:" "2.2. Emergency care provided to the patient prior to arrival, if any.""2.6 Any findings of assessments, reassessments or changes in clinic status. 2.7 Treatment goals, plan of care, and revisions to the plan of care." "2.19. Any progress notes" "2.24. Any access site for medication, administration devices used, and rate of administration."

2. On 10/16/19 Patient #5's medical record review was conducted with Staff C. The documentation review revealed the patient presented to the Emergency Department (ED) on 05/07/19 at 1:18 AM with complaints of chest pain and a ESI level of 2 (Emergent High risk of deterioration, or signs of a time-critical problem such as cardiac-related chest pain or asthma attack). The patient was admitted to the Medical Surgical/Telemetry unit and was discharged to home on 05/08/19 at 3:07 PM.

The medical record review for this encounter revealed a lack of nursing documentation and assessment of the patient's IV sites on 05/07/19 for an IV in the right arm. The record lacked documentation of the insertion site of the IV, the gauge size of needle, and which nursing employee performed the procedure. The medical record revealed the patient also had a peripheral IV in the left arm. The patient was receiving physician ordered IV fluids and medication (potassium); however, the documentation by nursing was silent to which IV site was used to administer the fluids and medication.

On 05/08/19 at 11:56 PM, the patient presented to the ED with a complaint of right arm pain status post IV insertion on the previous visit encounter (05/07/19). The patient was evaluated by a resident physician and the attending emergency department physician. The patient was discharged home on 05/09/19 at 12:33 AM. The diagnosis for this encounter was superficial thrombophlebitis (in right arm).

On 05/10/19 at 4:31 AM the patient presented to the ED with complaints of chest pain and an ESI level of 2. During this encounter, the patient coded at 8:06 AM with unsuccessful cardiopulmonary resuscitation and expired at 8:39 AM. On 05/10/19 nursing documentation revealed the patient had two physician ordered IVs in the left arm during that encounter. Documentation by Staff N on 05/10/19 at 4:45 AM revealed the patient had a peripheral IV with a 20 gauge needle inserted; however, the documentation was silent to the IV site location. The medical record did contain documentation of a second peripheral IV in the antecubital space of the left arm placed at 6:20 AM on 05/10/19 by Staff O. Although the patient was receiving intravenous fluids, the nursing documentation was silent to which IV site was used for the fluids.

Interview with Staff C on 10/16/19 at 4:25 PM confirmed the aforementioned policies were not followed in regard to IV insertion assessment and infusion of IV fluids and medications for Patient #5.

This deficiency substantiates Substantial Allegation OH00107283.

ORGANIZATION OF EMERGENCY SERVICES

Tag No.: A1102

Based on personnel file review, interview and review of the facility's contract for emergency specialists, the facility failed to ensure emergency services were under the direction of a qualified member of the medical staff. This had the potential to affect every patient in the emergency department. The average daily census of the emergency department was 60 to 70 patients per day.

Findings include:

The facility's Professional and Administrative services Agreement for Emergency Specialists (effective 01/01/13) stated the providers shall meet such other applicable requirements including all requirements set forth in Exhibit B. Exhibit B stated Physician requirements were Advanced Cardiac Life Support Certification and Pediatric Advanced Life Support Certification.

The credentialing and privileging file for Staff F contained PALS (Pediatric Advanced Life Support) certification which expired in June 2019 and ACLS (Advanced Cardiac Life Support) certification which expired in October 2018. The Emergency Medicine Privilege Form for Staff F stated the minimum requirements include ACLS and PALS.

The findings were shared with Staff B on 10/17/19 at 2:30 PM and confirmed.