HospitalInspections.org

Based on observations, policy and procedure review, medical record reviews, and staff interviews, the nursing staff failed to label IV (intravenous) tubing per hospital policy in 3 out of 5 patients. ( #13, #14 and #15.)

Findings include:

Review of the hospital's policy and procedure titled "IV TUBING CHANGE, SITE CARE, DRESSING CHANGE, AND REMOVAL, with revision date of 03/2015, revealed "...7. Label IV tubing with IV set change sticker with start date/time and discard date/time appropriate to the purpose of the tubing i.e. primary continuous or primary intermittent (secondary) tubing."

1. Open medical record review on 12/10/2015 revealed a 61 year old female admitted on 12/08/2015 after a fall, causing a subcapital femoral neck fracture. (#13)

Observation on Post surgical unit 2 on 12/10/2015 at 1330 revealed an IV in pt's (patient's) #13 hand without label on primary IV tubing.

Interview with RN #1 on 12/10/2015 at 1330 revealed tubing should be labeled as per policy.

2. Open medical record review on 12/10/2015 revealed a 73 year old female admitted on 12/09/2015 for right knee pain. (#14)

Observation on Post surgical unit 2 on 12/10/2015 at 1335 revealed an IV in pt's #14 hand without label on primary IV tubing.

Interview with RN #1 on 12/10/2015 at 1330 revealed tubing should be labeled. Interview revealed tubing was not labeled per policy.

3. Open medical record review on 12/10/2015 revealed a 75 year old male admitted on 12/09/2015 for Right Total Knee Arthroplasty (surgical procedure to remove inflammed tissues).

Observation on Post surgical unit 2 on 12/10/2015 at 1335 revealed an IV in pt's #15 hand without label on primary IV tubing.

Interview with RN #1 on 12/10/2015 at 1330 revealed tubing should be labeled as per policy.

NC00111535