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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to ensure nursing care was provided and met the continuous care needs of the patient. Specifically, nursing staff failed to implement measures to prevent a new pressure injury or prevent further injury once a pressure injury was identified for one of three wound patient medical records reviewed (Patient #2). Additionally, nursing staff failed to provide care to patients with percutaneous endoscopic gastrostomy (PEG) tubes in accordance with physician orders and facility policy for one of one medical records reviewed of a patient with a PEG tube (Patient #2). In addition, the facility failed to ensure peripheral intravenous catheters (PIVC) were monitored and maintained according to nationally recognized guidelines for one of one medical records reviewed of a patient with a PIVC infiltration and occlusion (Patient #2).

Based on interviews and document review, the facility failed to ensure nursing care was provided and met the continuous care needs of the patient. Specifically, nursing staff failed to implement measures to prevent a new pressure injury or prevent further injury once a pressure injury was identified for one of three wound patient medical records reviewed (Patient #2). Additionally, nursing staff failed to provide care to patients with percutaneous endoscopic gastrostomy (PEG) tubes in accordance with physician orders and facility policy for one of one medical record reviewed of a patient with a PEG tube (Patient #2). In addition, the facility failed to ensure peripheral intravenous catheters (PIVC) were monitored and maintained according to nationally recognized guidelines for one of one medical records reviewed of a patient with a PIVC infiltration and occlusion (Patient #2).

Findings include:

Facility policies:

The Assessment and Reassessment policy read, patients receiving inpatient, outpatient or emergency services will have an initial assessment and appropriate follow-up assessments based on their individual needs, including physical, psychological, spiritual and social/cultural status. The data collected from each assessment will identify the patient's needs and the type of care to be provided. The goal of the assessment/reassessment process is to provide the patient with the best care and treatment possible. The assessment framework will be structured around two components: initial screening/assessment and reassessment of all patients as appropriate to the clinical discipline and individual patient condition. Each patient is to be reassessed as needed and according to the guidelines established by the department or clinical discipline. The assessment process will be collaborative to facilitate, identify and prioritize the patient's needs and determine care. Shift assessments will be done once a shift. Scope and Responsibilities of Involved Disciplines: Nursing: at the time of admission, each patient will have his or her needs assessed by a registered nurse (RN). The admission assessment will be completed by the RN as soon as possible upon arrival to the nursing unit, but will not exceed established parameters for each unit. Patient condition upon arrival may warrant immediate assessment. Reassessments will be completed based on unit parameters.

The Wound Management policy read, a complete skin assessment is required upon admission to the hospital and repeated every 12 hours during the RNs physical assessment. A complete skin assessment should also be completed if there are significant changes in the individual's medical condition, skin or deterioration of wound(s). Documentation of skin assessment findings is required. Wounds are to be documented and measured within 24 hours of admission, weekly on Wednesdays, at discharge, or any time there is a change in the wound appearance. A "Wound Care Consult" must be initiated with all abnormal or concerning skin and wound findings. Minimizing pressure and preventing skin breakdown include turning and repositioning and is required every two hours. Assess the sacral area frequently if unable to lower the head of bed. Use a specialty bed or chair if appropriate as an adjunct therapy. It is, however, not a replacement to repositioning schedules. Order specialty mattresses through the medical record system under "Bed (Request Special Bed Equipment)".

The Bed Requests, Storage, and Mattress Selection policy read, Specialty Mattress Selection/Indications for Mattress Use: Guidelines for selection of a specialty mattress. Patients with the following diagnoses and/or conditions will be automatically eligible for a specialty mattress: bed-bound, hospital-acquired pressure injuries, and physician-specific admission order.

The Enteral Nutrition policy read, to avoid clogged feeding tubes staff were to review all medications with pharmacy to ensure proper administration, and to flush the tube well with water before and after putting formula, medication or anything else in the tube, as well as routinely flush the tube according to the enteral nutrition order. For medication and enteral nutrition administration, stop enteral nutrition prior to the administration of medications. Flush the tube with at least 30 ml of water before and after giving medications through the tube. Give each medication separately and flush the tube with 5 ml of warm water between medications. Water flushes: During continuing feeds, 30 ml of sterile water or normal saline should be flushed through the tube every four hours or as per the provider and dietitian recommendations. During intermittent feeds, 30 ml of sterile water or normal saline should be flushed before and after the feed or as per the provider or dietitian. After gastric residual volume (GRV) measurements, 30 ml of sterile water or normal saline should be flushed.

The Documentation - Patient Care Areas policy read, documentation will reflect the coordination of care and care planning performed by the registered nurse in collaboration with other members of the healthcare team. Documentation must be completed within scope of practice and by the person completing the care. Care Activities: Routine care activities appear on the worklist for each patient. These specific interventions are not tied to problems or goals and are not part of the Plan of Care. Routine care activities include: Intake and Output; Lines, Drains and Airways.

The Vascular Access policy read, facility placed peripheral intravenous (IV) insertion sites will be changed only as needed, such as if there are any signs of complications (e.g. pain, infection, phlebitis, or infiltration). Peripheral IVs no longer need to be changed automatically every 96 hours.

Reference:

The Wound Care Reference Guide read, patients who were immobile were considered "at risk patients". Specialty bed selection guidelines: the P500 air mattress was recommended for paraplegic (inability to move the lower parts of the body voluntarily) patients without current pressure injuries. The Dolphin (Immersion/Air) Bed and Envision (Immersion/Air) Bed were recommended for all quadriplegics (inability to voluntarily move the body and extremities from the neck down) and paraplegics with pressure injuries and patients with prolonged immobility. Sacral pressure injury prevention: a 5-Layer sacral foam dressing is recommended for protection against skin breakdown for at risk patients. The sacral foam dressing is assessed every shift and changed every three days and as needed if soiled. The sacral foam dressing will be labeled "PIP" (pressure injury prevention) with the date, time, staff member initials, and the date of the next dressing change. Do not use sacral foam dressings on incontinent patients unless urine and fecal containment devices are in place. A wound care consultation is needed for any hospital acquired pressure injury, and any stage 3, 4, unstageable, deep tissue injury (DTI) and medical device related pressure injury.

National Guidelines provided by the facility:

The Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, read, replacement of peripheral and midline catheters. There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce the risk of infection and phlebitis. No recommendation is made regarding the replacement of peripheral catheters in adults only when clinically indicated. Scheduled replacement of intravascular catheters has been proposed as a method to prevent phlebitis and catheter-related infections. Studies of short peripheral venous catheters indicate that the incidence of thrombophlebitis and bacterial colonization of catheters increases when catheters are left in place for > 72 hours. Because phlebitis and catheter colonization have been associated with an increased risk for catheter-related infection, short peripheral catheter sites commonly are replaced at 72-96 hour intervals to reduce both the risk for infection and patient discomfort associated with phlebitis.

The Infusion Therapy Standards of Practice read infusion therapy standards of practices are applicable to any patient population and any setting in which vascular, intraosseous (IO), subcutaneous, and intraspinal access devices are inserted and/or managed and where infusion therapies are administered. The needs and characteristics of special patient populations, including physiologic, developmental, communication/cognitive ability, and/or safety requirements, are identified and addressed in the planning, insertion, removal, care and management, and monitoring of vascular access devices (VADs) and with administration of infusion therapy. The appropriate type of VAD, peripheral or central, is selected to accommodate the patient's vascular access needs based on the prescribed therapy or treatment regimen, including anticipated duration of therapy, vascular characteristics, patient's age, comorbidities, history of infusion therapy, preference for VAD type and location, and ability and resources available to care for the device. In clinical practice, many parameters, including administration site, number of infusion therapies, vein selected, related venous blood flow, infusion volume, infusion time, and planned duration of therapy, contribute to vessel damage. Avoid peripheral intravenous catheter (PIVC) insertion in areas of: veins that are compromised (e.g., previous cannulation, bruised, reddened/streaked, infiltrated, sclerosed, corded, or engorged). Avoid venipuncture on an extremity with paralysis or hemiplegia (e.g., traumatic injury, cerebrovascular accident) when feasible, due to alteration in normal blood flow and decreased sensation that would prevent reporting pain associated with nerve injury and other complications. The VAD Selection and Placement section read, the factors to consider when selecting the most appropriate VAD include, but are not limited to: the method of administration (e.g., continuous or intermittent infusion or manual injection), infusion rate, number of infusion therapies (single vs multiple) and anticipated duration of therapy. Anticipated duration of infusion therapy guide: for infusion therapy lasting <4 days, insert a peripheral intravenous catheter (PIVC). Infusion therapy lasting 5-14 days, insert a midline catheter in hospitalized adult patients.

1. The facility failed to implement measures to prevent pressure injuries and skin breakdown for a paraplegic patient.

a. Medical record review revealed Patient #2 obtained an immobility pressure injury on his left buttocks after he was admitted to the facility.

i. On 1/31/23 at 6:23 p.m. Patient #2 was transported by ambulance to the emergency department (ED). According to the Emergency Provider Report entered on 1/31/23 at 7:21 p.m., Patient #2 had an antibiotic-resistant urinary tract infection (UTI) and required inpatient medical treatment and evaluation. At 9:19 p.m., Patient #2 was admitted as an inpatient at the hospital; however, Patient #2 remained in the ED until an inpatient bed became available on 2/1/23 at 3:45 p.m.

ii. On 2/1/23 at 2:18 a.m., registered nurse (RN) #4 performed the nursing inpatient admission assessment for Patient #2 while the patient was still in the ED. According to the inpatient admission assessment performed by RN #4, Patient #2 was non-ambulatory and incontinent. There was no evidence Patient #2 had an existing immobility pressure injury on his left buttocks when RN #4 performed the admission skin assessment for Patient #2.

iii. On 2/1/23 at 3:45 p.m., (18 hours and 26 minutes after admission) Patient #2 was physically transported from the ED to an inpatient room. A Nurse Shift Assessment performed by RN #3 on 2/1/23 at 6:44 p.m., (21 hours and 25 minutes after admission) revealed Patient #2 had an immobility pressure injury on his left buttock.

According to the shift assessment, the immobility pressure injury discovered on Patient #2's left buttock was barely blanchable (the skin did not lighten or turn white when touched) and appeared purple, maroon, and deep reddish in color. However, there was no evidence of Patient #2's physician had been notified of the pressure injury. Additionally, there was no evidence a wound consultation to evaluate the pressure injury had been ordered.

Prior to the discovery of the immobility pressure injury on 2/1/23, there was no evidence a specialty mattress had been ordered to prevent skin breakdown for Patient #2.

This was in contrast to the Wound Management policy and the Wound Care Reference Guide which read, a wound care consultation will be ordered for all abnormal wound findings. Additionally, a wound care consultation was required for patients who acquired hospital-related pressure injuries and DTIs. Furthermore, according to the Wound Care Reference Guide bed bound and immobile patients incapable of self repositioning and ambulation had an increased risk of skin breakdown needed to be ordered a speciality mattress.

iv. A review of wound care, dressing changes, and wound assessments was performed for Patient #2. The medical record lacked evidence of dressing changes and wound assessments.

On 2/1/23 at 6:51 p.m., RN #3 documented she cleansed the immobility pressure injury on Patient #2's left buttock, applied barrier cream, and covered the area with a foam dressing to protect against further skin breakdown and injury. However, the foam dressing applied by RN #3 was not removed or changed until five days later on 2/6/23 at 9:00 a.m.

This was in contrast with the Assessment and Reassessment policy and the Wound Care Reference Guide which read foam dressings would be assessed by the nurse during every shift and the foam dressing would be changed every three days and or when the foam dressing became soiled.

v. A further review of the nursing skin integrity assessments revealed no evidence nursing staff performed a skin integrity assessment during the night shift on 2/2/23, 2/3/23, 2/4/23, and 2/8/23. Additionally, there was no evidence nursing staff performed a skin integrity assessment during the day shift on 2/5/23 and 2/9/23.

This was in contrast with the Assessment and Reassessment policy and the Wound Care Reference Guide provided by the facility which read, nursing shift assessments would be performed once a shift and would identify specific treatment and nursing care needed for each patient.

b. Interviews with staff revealed no evidence nursing staff followed facility policy and wound care guidelines when nursing care was provided to Patient #2.

i. An interview was conducted with RN #4 on 4/11/23 at 11:23 a.m. RN #4 stated she was an inpatient nurse at the facility. RN #4 stated on 1/31/23 she provided inpatient nursing care to patients who were boarded in the ED awaiting inpatient room assignments. RN #4 stated she performed the inpatient admission assessment for Patient #2.

RN #4 stated Patient #2's inpatient admission assessment occurred while Patient #2 was boarded in the ED, waiting for a room to open in the inpatient unit. RN #4 stated patients boarded in the ED were considered inpatients. RN #4 stated patients boarded in the ED received nursing care from inpatient nurses, not ED nurses.

RN #4 stated patients boarded in the ED were not provided inpatient beds while boarded in the ED. RN #4 stated patients boarded in the ED were provided stretchers to lay on in the ED rooms. RN #4 stated she was unsure if a specialty bed could be provided to patients boarded in the ED. RN #4 stated Patient #2 did not have a wound present on his back or buttocks when she performed Patient #2's inpatient admission assessment on 2/1/23 at 2:18 a.m.

ii. On 4/12/23 at 11:13 a.m., an interview was conducted with RN #3. RN #3 stated she performed the Nurse Shift Assessment on 2/1/23 at 6:44 p.m. RN #3 stated Patient #2 had a pressure injury present when she performed the Nurse Shift Assessment on 2/1/23. RN #3 stated Patient #2 was a paraplegic, bedbound, and incontinent. RN #3 stated a foam dressing was applied to the pressure injury on Patient #2's left buttock to prevent further skin breakdown.

RN #3 stated she was unable to recall when a wound consultation was required to be ordered. RN #3 stated she had not discussed the placement of a wound consultation for Patient #2 with Patient #2's physician.

iii. On 4/10/23 at 2:27 p.m., an interview was conducted with Wound Care Nurse (WC Nurse) #7. WC Nurse #7 stated wound consultations were ordered for patients who had existing wounds, developed a wound, or for any skin related concern. WC Nurse #7 stated immobile, incontinent, and immunocompromised patients had an increased risk for skin breakdown, pressure injury, and infection. WC Nurse #7 stated a patient would not be seen by a wound care nurse unless a wound care consultation was ordered. WC Nurse #7 stated patients were at risk for harm and deterioration of health when interventions to prevent wounds were not implemented for patients.

iv. An interview was conducted with Nurse Manager (Manager) #6 on 04/12/23 at 12:19 p.m. Manager #6 stated patients boarded in the ED were cared for by inpatient nurses. Manager #6 stated nurse assessments were expected to be performed when the patient was admitted as an inpatient, when the patient transferred units, and once per nursing shift.

Manager #6 stated nurses were able to initiate and implement wound prevention measures for patients. Manager #6 stated the application of foam dressings and specialty bed usage were considered wound prevention measures. Manager #6 stated paraplegic patients were at risk for developing wounds due to immobility. Manager #6 further stated incontinent patients were at risk for wounds. Manager #6 stated a wound consultation was needed for patients with existing wounds and for patients who developed a wound while hospitalized.

2. The facility failed to ensure nursing staff implemented measures to prevent PEG tube occlusion. Specifically, nursing staff failed to perform, monitor, and document enteral nutrition intake (liquid nutrition delivered directly into the gastrointestinal tract), free water intake (the amount of water delivered directly into the gastrointestinal tract), and free water flushes (administration of water into a feeding tube to maintain hydration and to prevent the feeding tube from clogging) for a patient with a PEG tube according to physician orders and facility policy.

a. Patient #2's medical record was reviewed and revealed Patient #2 had a tracheostomy tube (a plastic tube placed in a surgically created opening at the front of the neck to facilitate breathing), dysarthria (when the muscles used for speech become weakened or paralyzed and cause slurred speech), dysphasia (difficulty swallowing food and liquids) and was dependent on a PEG tube for nutrition and medication administration due to chronic aspiration (accidental inhalation of food or liquid into the airway).

i. On 2/1/23 at 12:46 p.m., the physician assistant (PA) entered an order which read, 30 milliliters (ml) of free water was to be flushed through the patient's PEG tube before and after medication administration. The order also specified an additional 60 ml of free water was to be flushed through the PEG tube every four hours.

Additional orders the PA entered on 2/1/23 included an order for intake and output monitoring, an order for continuous tube feedings via a pump, and an order for baclofen (a muscle relaxant used to relieve spasms and tightness of muscles) at a dosage of 10 milligrams (mg) to be administered three times a day via the patient's PEG tube.

ii. Review of the intake and output documented by nursing staff during Patient #2's hospitalization revealed multiple occasions in which there was no evidence the free water flushes were performed. Examples include:

On 2/1/23 at 2:18 a.m. and 6:44 p.m. there was no documentation in the Intake/Output flow sheet of free water intake or flushes performed.

On 2/2/23 at 12:25 a.m., 8:55 a.m., and 8:45 p.m. there was no documentation of free water intake or flushes.

On 2/4/23 at 8:56 a.m. and 8:30 p.m. there was no documentation of free water intake or flushes.

Similar findings of no free water intake or flushes performed were noted for each day of Patient #2's hospitalization from 2/1/23 to 2/9/23.

The Intake and Output documentation was in contrast to facility policy, which read documentation was to include routine care activities such as intake and output. The intake and output documentation was also in contrast with the PA's order which specified free water flushes were to be performed during medication administrations and every 4 hours, and monitoring of the patient's intake and output was to occur.

iii. According to a Hospitalist Progress Note entered by the physician on 2/5/23 at 1:42 p.m., the physician consulted Interventional Radiology (IR) because Patient #2's PEG tube was clogged. The note further read, the patient's tube feedings and free water flushes were to be held due to the clogged PEG tube.

iv. In a Hospitalist Progress Note entered on 2/6/23 at 4:28 p.m., the physician documented nursing staff had reported Patient #2 had a new fever, tachycardia (elevated heart rate) and hypertension (elevated blood pressure) that morning. The physician documented based on the overall clinical picture it was felt the patient was experiencing baclofen withdrawal, as the patient had not received baclofen since the PEG tube became clogged the previous day.

According to the hospitalist's note, a trial of intravenous (IV) Ativan (a benzodiazepine medication that acts on the central nervous system to produce a sedative effect) was given and the patient was started on a CIWA protocol (a medical protocol which included administration of Ativan, commonly used for alcohol withdrawal symptoms) for baclofen withdrawal.

b. Interviews revealed nursing staff were responsible to monitor patient intake and output as directed by providers' orders and facility policy. Interviews with staff further revealed Patient #2's intake and output, specifically free water flushes and intake, were not monitored according to physician order and policy throughout his hospitalization.

i. On 4/10/23 at 4:56 p.m., RN #1 was interviewed. RN #1 stated when a patient had a PEG tube, orders were placed for tube feeding which included the rate and type of nutrition to be given via the PEG tube. He stated the order would also include the amount of free water to administer into the feeding tube to ensure the tube did not become blocked or occluded. RN #1 stated for a patient receiving continuous tube feedings throughout the day, the patient would also receive free water flushes at specific intervals throughout the day.

RN #1 stated free water was important for a patient's hydration if the patient was on tube feedings, and to ensure an occlusion or clog in the feeding tube did not occur. He stated free water flushes were performed when medications were administered via a PEG tube, and the standard amount of free water flush given medication administration was 30 ml.

RN #1 stated there was not a specific area of the patient's medical record where staff documented free water flushes or intake.

ii. On 4/12/23 at 11:13 a.m., Registered Nurse (RN) #3 was interviewed. RN #3 stated patients with PEG tubes required sterile water flushes every shift, as well as before and after medication administration, because PEG tubes were prone to clogging and getting occlusions. RN #3 stated patients who had PEG tubes were at risk for PEG tube occlusions. RN #3 stated enteral nutrition and the medications administered via a PEG tube would have to be stopped if the PEG tube became occluded.

iii. On 4/11/23 at 1:36 p.m., the clinical pharmacy manager (Manager) #2 was interviewed. Manager #2 stated baclofen was a medication administered to patients with spinal injuries and spasticity (involuntary stiffening or tightening of the muscles). Manager #2 stated baclofen decreased muscle spasms and dystonia (a movement disorder which causes muscles to contract involuntarily). Manager #2 stated baclofen could not be abruptly stopped, and patients taking baclofen had to be slowly weaned off the medication. She stated when baclofen was stopped abruptly the patient was at risk for severe spasticity rebound (increased muscle tightening and prolonged muscle contraction).

Manager #2 stated when Patient #2's PEG tube became clogged on 2/5/23, the patient subsequently missed a total of four doses of baclofen and did not receive baclofen for over 24 hours. She stated the physician then ordered IV Ativan to be administered and the patient was placed on the CIWA withdrawal protocol. Manager #2 stated possible symptoms of spasticity included sweating and agitation which could mimic withdrawal symptoms. She reviewed the physician's note entered on 2/6/23 and she stated because the physician determined Patient #2 was experiencing baclofen withdrawal, the patient was placed on the CIWA protocol and treated with Ativan to address his symptoms.

3. The facility failed to ensure nursing staff monitored and maintained peripheral intravenous (PIV) catheters according to nationally recognized guidelines.

a. According to the Infusion Nurses Society guidelines provided by the facility, the location of the peripheral intravenous catheter (PIVC) placement should be based on the intravenous fluid replacement treatment and the duration of the infusion therapy. Avoid placement of PIVC in previously cannulated (insertion of a small plastic tube into a vein), bruised, reddened, streaked, infiltrated veins and PIVC placement in the hand, wrist, and upper arm. Additionally, under the VAD Selection and Placement section, PIV catheters were used for infusion therapies lasting <4 days and midline catheters were used for infusion therapies lasting 5-14 days.

b. According to the Guidelines for the Prevention of Intravascular Catheter-Related Infections, routine and or scheduled replacement of intravascular catheters assisted to prevent phlebitis and other catheter-related infections. Additionally, the replacement of short peripheral catheter sites at 72-96 hour intervals was recommended to reduce the risk for catheter-related infections.

c. Medical record review for Patient #2 revealed the patient received continuous intravenous fluid replacement therapy and intravenous antibiotic medications from 1/31/23 through 2/9/23.

i. According to the flow chart in the emergency medical services (EMS) ambulance report for Patient #2, on 1/31/23 at 5:54 p.m., EMS staff attempted to insert an 18 gauge (the inner measurement or opening of the needle) PIVC into Patient #2's left forearm and was unsuccessful. At 5:58 p.m., EMS staff attempted a second time to insert a PIVC. EMS attempted to insert a 20 gauge PIVC into the left antecubital (area in front of the elbow) of Patient #2's arm. The attempt was also unsuccessful. At 6:00 p.m., a third attempt to place a PIVC was made by EMS staff. EMS staff were able to successfully place a 20 gauge PIVC into Patient #2's left forearm to administer intravenous fluids to Patient #2.

ii. Review of Patient #2's emergency patient record revealed Patient #2 was paraplegic with left sided hemiplegia. On 1/31/23 at 7:26 p.m., RN #8 inserted a 20 gauge PIVC into Patient #2's left upper arm. Further review of the ED nursing care flow sheet for Patient #2 revealed the PIVC placed by RN #8 on 1/31/23 was used to administer continuous intravenous fluids and intravenous antibiotic medications for seven of the nine days Patient #2 had been hospitalized.

According to the Infusion Therapy Standards of Practice, extremities affected by hemiplegia had altered blood flow and decreased sensation, additionally, PIVC placement on hemiplegic extremities should have been avoided to prevent nerve injury and other complications.

iii. On 2/6/23 at 12:30 p.m., six days after the PIVC was inserted, the nursing care flow sheet revealed the PIVC site located in Patient #2's left upper arm was edematous and the PIVC had infiltrated (the tip of the PIVC came out of the vein and intravenous fluids and medications leaked into the surrounding tissue). At 1:35 p.m., Patient #2 had an ultrasound (a procedure used to assess for blood clots) performed on his upper left arm. According to the ultrasound findings, Patient #2 had a blood clot in the cephalic vein (one of the two main veins in the arm). The hospitalist progress note entered on 2/6/23 at 4:48 p.m. documented Patient #2's left upper arm was swollen and edematous.

d. Staff interviews revealed PIVCs were not removed or discontinued unless the patient developed a complication.

i. An interview with RN #3 was conducted on 4/12/23 at 11:13 a.m. RN #3 stated PIVCs were assessed every shift by the RN. RN #3 stated PIVC assessments were important to ensure superficial thrombophlebitis (an inflammatory process that causes a blood clot to form and block the vein) did not occur. RN #3 stated PIVCs were assessed by flushing (injecting a sterile solution of salt and water into the PIVC) the PIVC to ensure the catheter worked and the vein was not blocked, infiltrated, or painful.

ii. On 4/10/23 at 3:52 p.m., an interview was conducted with the vice president of quality (VP of Quality) #10. VP of Quality #10 stated PIVCs were not required to be discontinued or removed unless the patient experienced a complication with the PIVC. VP of Quality #10 further stated possible PIVC complications included infiltration (leaking of non-harmful fluid into the tissues surrounding the vein), extravasation (leaking of a fluid that irritates the tissues surrounding the vein and causes injury to the tissues), phlebitis (inflammation in the vein), infection, and occlusion of the vein (blood clot in the vein). VP of Quality #10 stated nurses were educated PIVC were to remain in place and should not be changed or removed unless a complication with the PIVC occurred.

According to an email correspondence provided to surveyors on 4/14/23 at 8:54 a.m. from VP of Quality #10, the Infusion Nursing Society (INS) standards and guidelines and the manufacturer's instructions from the PIV catheters were expected to be followed. The email communication further stated INS standards and guidelines did not advise when a PIVC should be discontinued or removed.

These interviews and the Vascular Access policy were in contrast to the INS, Infusion Therapy Standards of Practice which stated the duration of the infusion therapy should have been used to determine which type of vascular access device to place. Additionally, PIVCs should have been used for infusion therapy lasting less than four days, and for infusion therapies greater than four days, selection of a different vascular access device should have occurred. In addition, CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections stated PIVCs should have been discontinued, removed, and replaced after 72-96 hours.