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Based on interview and record review, the hospital failed to develop the individualized nursing care plan related to shortness of breath and risk of bleeding due to the administration of continuous IV heparin (blood thinning medication) infusion for one of five sampled patients (Patient 2). This failure created the risk of not meeting Patient 2's care needs.

Findings:

Review of the hospital's P&P titled Multidisciplinary Plan of Care dated September 2023 showed each admission will have a written multidisciplinary plan of care utilized by all disciplines. Expected outcomes/goals will be based on assessment and will be realistic, measurable, and consistent with the therapy prescribed by the patient's physician and other clinical disciplines. Patient education and patient/family knowledge of self-care will be given special consideration in the nursing plan.

Review of Patient 2's closed medical record was initiated on 4/16/25. The medical record showed Patient 2 was admitted on 1/3/25.

Review of Patient 2's H&P examination dated 1/3/25, showed Patient 2 was admitted to the hospital with a chief complaint of increasing shortness of breath over the last several days and was diagnosed with acute pulmonary embolus.

Review of Patient 2's physician's order dated 1/3/25, showed an order to start heparin, 25000 units in D5W (Dextrose 5% in water, an IV solution) 250 mL, continuous IV infusion

On 4/16/25 at 1401 hours, an interview and concurrent review of Patient 2's closed medical record was conducted with Nursing Director 1. Nursing Director 1 stated the nursing care plans should be individualized to reflect the patient's current health conditions and care needs. However, Nursing Director 1 was unable to find the care plans developed to address Patient 2's shortness of breath and risk of bleeding related to continuous IV heparin infusion. Nursing Director 1 acknowledged Patient 2's care plan was not individualized to address their specific needs.

On 4/16/25 at 1215 hours, the Chief Nursing Officer and Performance Improvement Director were notified and acknowledged the above findings.

Based on observation, interview, and record review, the hospital's failed to implement their P&Ps and physician's orders for one of five sampled Patients (Patient 5) as evidenced by:

1. RN 5 did not perform hand hygiene prior to administering the medications as required by the hospital's P&P.

2. RN 5 did not access Patient 5's central line device as per the hospital's P&P.

3. There was no documentation to show RN 5 notified the physician before administering insulin glargine (a long-acting insulin used to manage blood sugar levels in people with diabetes) to Patient 5 while the patient was on NPO as per the physician's order.

These failures had the potential to increase the risk of substandard healthcare outcomes and safety to the patient.

Findings:

1. Review of the hospitals P&P titled Medication Administration dated September 2024 showed aseptic technique, IV, and infection control practices will be adhered to in the preparation and administration of medications.

On 4/17/25 at 0845 hours, a medication pass observation was conducted with RN 5. RN 5 was observed exiting the nursing station and holding Patient 5's medications. RN 5 then pushed a workstation on wheels and a mobile computer cart into Patient 5's room, and donned the gloves. RN 5 did not perform hand hygiene before donning the gloves. RN 5 then accessed Patient's 5 electronic medical record and administered one medication via subcutaneous injection and one medication via IV push to Patient 5.

On 4/17/25 at 0854 hours, an interview was conducted with RN 5. RN 5 acknowledged hand hygiene was not performed before administering medication to Patient 5 or before donning gloves.

On 4/17/25 at 1003 hours, an interview was conducted with the Infection Preventionist. The Infection Preventionist confirmed hand hygiene should always be performed immediately before administering medication to a patient.

2. Review of the hospital's P&P titled Care of Central Venous Catheters dated March 2020 showed the hospital adopts the recommendations provided by the CDC and the IHI for the prevention and reduction of CR BSI.

Review of the CDC's Guidelines for the Prevention of Intravascular Catheter-Related Infections dated 2011 showed the recommendations for needleless intravascular catheter systems include to minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices.

On 4/17/25 at 0845 hours, RN 5 was observed scrubbing Patient 5's CVC access port with a 70% alcohol prep pad. However, after scrubbing the access port of the CVC, RN 5 was observed placing the access port on Patient 5's right shoulder allowing the port to come into contact with Patient 5's pillow and gown. RN 5 was then observed to administer a medication via the CVC port to Patient 5.

On 4/17/25 at 0854 hours, an interview was conducted with RN 5. RN 5 stated the CVC port had come into contact with Patient 5's pillow and gown, and this practice could increase the risk of a catheter-related bloodstream infection.

On 4/17/25 at 1003 hours, an interview was conducted with the Infection Preventionist. The Infection Preventionist stated when working with central lines, once the injection port was cleaned with alcohol, it should be not placed where it could be re-contaminated prior to the administration of IV medications.

3. Review of the hospital's P&P titled Medication Administration dated September 2024 showed prior to administration, the practitioner will review the medication administration record (MAR) for any special considerations that would influence the administration of medications, including but not limited to clinical parameters, NPO status, medications at odd hours, one time only medications, or medications that must be given with food.

On 4/17/25 at 0845 hours, a medication pass observation was conducted with RN 5. RN 5 was observed administering 10 units of insulin glargine to Patient 5.

Review of Patient 5's physician's orders showed the following orders:

- The physician's order dated 4/13/25 at 1316 hours, showed insulin glargine 10 units subcutaneous, every 12 hours, notify MD if the patient is NPO for procedure when there are no IV fluids with dextrose (an IV fluid used to treat low blood sugar) running or no orders for temporary decrease of insulin glargine

- The physician's order dated 4/16/25 at 1858 hours, showed NPO after midnight.

On 4/17/25 at 0946 hours, an interview and concurrent review of Patient 5's medical record was conducted with Nursing Director 1 and RN 5. RN 5 stated Patient 5 was scheduled for a procedure and was NPO, RN 5 also confirmed Patient 5 did not have an order for IV fluids with dextrose or any order for a temporary decrease of insulin glargine. RN 5 stated the physician was not notified, and Patient 5 received 10 units of insulin glargine without the required physician's notification. Nursing Director 1 was unable to locate documentation in Patient 5's electronic medical record showing the physician was notified as required prior to the administration of the insulin glargine.

On 4/16/25 at 1215 hours, the Chief Nursing Officer and Performance Improvement Director were notified and acknowledged the above findings.