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Based on record review and interview, the facility failed to ensure a systemic plan of correction for assessing complications of intravenous (IV) therapy and implementing safe treatment to prevent injuries for 1 (#1) of 11 patients.


The findings include:


Patient # 1 has a history of Quadriplegia and sustained severe swelling and blisters to their left hand and arm on 4/29/17 at 3:56 AM, when Employee # B, an RN, applied hot compresses without a barrier to their arm.


A review of the medical record for Patient #1 revealed no orders for the application of heat compresses.


An interview was conducted with Employee F, Nurse Director, on 6/19/2017 at 2:38 PM. Employee F stated, "We are meeting as a team; Root Cause Analysis (RCA) is currently in process. The RCA actually began; I know I found out about the incident on May 1, 2017. I interviewed the patient, started interviewing the staff that were on and intimately involved; I reviewed the variance. I spoke with the patient's mother and spoke multiple times with Risk Management. The Risk Management and Quality team initiated that. I have not yet presented this information in a Safety Committee. Employee F stated that she "has been discussing the event with the IV and warm compresses since the last meeting in huddles, that staff will not make warm compresses on this unit." No additional information to reinforce nursing skills on IV infiltration, discontinuing an IV site and the application of heat compresses to a patient was presented and made available as part of the facility-wide correction.


Interviews were conducted with Employee C, Staff Nurse, on 6/19/2017 at 3:17 PM and Employee D, Staff Nurse on 6/19/2017 at 2:19 PM, and each employee could not independently verify a new in-service, huddle or additional education related to IV assessment and management. On the 6/6/17 visit to the facility, there were no corrective actions documented. Only Employee F, Nurse Director, could present real time in-service documentation that specifically outlined the assessment and use of warm compresses for an infiltrated IV site on 6/19/2017. A review of the second floor unit huddle information only had one discussion documented since April 23, 2017 to 6/19/2017 that was reviewed. This huddle only referenced a vascular access for PICC line insertions.


An interview was conducted with the Chief Nursing Officer on 6/19/17 at 6:12 PM, she could not confirm there was a new educational plan already in place. She stated, "We would have our implementation; update the policy to move away from Lippincott; add to our IV competency and how to manage IV infiltration. Educate current staff using our educators on the unit. Then, we would address education with oncoming staff and new staff; what is key; we have a new device and people are educated to the why; and you know nurses, it has to be there. We have to get out there and follow-up when they ask questions. Before we go to change the process and does it make sense to do an assessment every four hours, if we are looking at the IV when we are using it, we will make sure that we have the best practice."


There was no information received from Quality Management upon request to support a documented response to educate nursing staff about IV infiltration, discontinuing an IV site and reassessing the implemented intervention for outcome.

A385

Based on record review and interviews, the facility failed to follow acceptable standards of care and practice in the removal of a plastic adhesive dressing that resulted in skin removal; failed to apply a warm compress correctly to 1 (#1) of 11 sampled patients; failed to document nursing intervention for Patient #1; failed to follow physician orders for Patient #11. These failures resulted in harm to Patient #1, resulting in severe swelling and blisters to the patient's left hand, which led to the Condition of Participation for Nursing.


The findings include:


See A 396

Based on record review and interviews, the facility failed to (1) ensure the development and implementation of a safe care plan to treat an IV infiltration. An unsafe practice resulted in severe swelling and blisters to the left hand of 1 (#1) of 11 sampled patients, who was desensitized; an inappropriate technique to remove an IV dressing to Patient #1 resulted in removal of skin from the left arm; (2) failed to discontinue intravenous fluids as ordered by the Physician for Patient #11.


The findings include:


(1) Patient # 1 has a history of Quadriplegia. Interview with the mother for Patient #1 on 6/5/17 at 9:47 am revealed that the Registered Nurse placed a hot compress directly on her son's skin that resulted in blisters.


A review of the medical record for Patient #1 revealed that on 4/29/2017 at 7:15 AM, nursing staff documented under skin alteration, the following: "Blister anterior hand left with a visible wound base that is blanchable and determined to be a partial thickness wound which is approximated."


On 4/29/17 at 7:27 AM, it was documented on Patient Assessment, "Patient #1 IV infiltrated on left hand, swelling and blisters."


On 5/01/17 at 1:17 PM, it was documented for IV assessment that, "this RN observed left hand blisters while the wound care nurse was applying dressing. Director of the floor notified of hand blisters. Pictures taken and put on chart."


A review of the medical record for Patient #1 revealed no order for the application of a heat compress.

Review of skin protocol for Patient #1 documents at line 5 to "avoid hot water".

Review of pictures of the patient's left arm and hand revealed severe edema with blisters and an open wound to their left arm.


A review of the facility provided "Lippincott Procedures" for heat application revealed the following: Heat applied directly to the patient's body raises tissue temperature. It also enhances the inflammatory process. You should apply direct heat cautiously for patients with impaired sensation. Noted under applying warm compress or pack includes to "apply the compress or pack gently to the affected site. After a few seconds, lift it and check the skin for excessive redness, maceration, or blistering. When you are sure that the compress or pack is not causing a burn, assess the patient's skin at regular intervals. Remove the device if the skin shows excessive redness, maceration, or blistering or if the patient experiences pain or discomfort. After 15 to 20 minutes or as ordered, remove the compress or pack."


An interview was conducted with Employee D, Charge Nurse on 6/19/2017 at 2:19 PM for Patient #1. She was asked about the direct application of heat to a Quadriplegic patient that resulted in blisters to the patient's hand. She stated the following: "On that morning Employee E, the patient's staff nurse, had been assigned to Patient #1. The patient had a new wound on his left hand. She found out in report that morning from Employee B that the patient had an infiltrated IV and that when Employee B removed the tape from the IV site, some of the patient's skin came off."


An interview was conducted with Employee F, Nursing Services Director, on 6/7/17 at 10:15 am. Employee F stated that they do a huddle every day on day shift and will stay and catch night shift. She stated, "I would tell the Charge Nurse what to discuss." A recent discussion was about documentation and when to change IV sites. Employee F stated, "We had an IV infiltrate and we completed Root Cause Analysis (RCA). The team that was involved in the incident came in and the incident was discussed. The discussion was about not using heat packs, but they did not have an official discussion, as they were still doing Root Cause Analysis." She stated that when everything was in place, they would do education.


An interview was conducted with Employee F, Nursing Services Director on 6/19/2017 at 2:38 PM, She stated, "I found out about the incident on May 1, 2017. I interviewed the patient, started interviewing the staff that were on and was intimately involved; I reviewed the variance. I spoke with the patient's mother and spoke multiple times with Risk Management. The Risk Management and Quality team initiated the process for correction. I have not yet presented this information in a Safety Committee. The Surveyor asked the Clinical Director about the plan of correction. Employee F stated that she "was discussing that since the last meeting in huddles, that staff will not make warm compresses on this unit." The facility could provide no evidence of documentation for systemic correction to prevent injury to patients resulting from interventions for IV infiltrations.


A telephone interview was conducted with Employee B, previous staff nurse, on 6/22/17 at 12:58 PM, related to the skin blisters that resulted from direct heat to the skin of Patient #1 due to an Intravenous Infiltration (IV). He stated, "Patient #1 had an IV infiltration. During my shift, his IV infiltrated on his left hand. It was a little bit swollen; I took out the IV, elevated his arm and put a warm compress on it. We did not have warm compresses on the floor. I made sure that it was not too hot and I asked the patient about it. I asked him if he wanted me to take the warm towel off; initially, I put a towel between the skin and the bag. I took it off and I asked him are you sure it is not too hot? I changed the compress; I would soak them in the warm water again, wrench it, and put them in the bag. I did this about four times. The next nurse came on; I gave report and then Monday morning, I got the call; either morning or afternoon, I got the call about skin burns. We do not have an official warm compress on the floor; we have ice packs. I put warm towels in a bag. That is what we usually do. The towels are little wash cloths that we get and put them under warm water. We get the warm water from the Kitchen or Nutrition room. The warm water came from the Nutrition room sink. The last interaction with Patient #1 was about when I changed the compress. He looked up and looked back down. This was before 6:00 AM. I just know that he got burns; the Nurse Director told this to me. I have used this approach in the past. IV infiltration is what I thought it was. I did not document. I forgot to document that I took an IV out and put a new one in."


(2) An observation was made on 6/19/17 at 2:53 PM while conducting an interview with sampled Patient #11. The observation was of an IV pump turned on, connected to the IV port for Patient #11 and was observed infusing at 10 milliliters an hour; observed in handwritten orange marker on the IV bag infusing is D5 1/2 NS at 50 milliliters an hour. The documented infusion rate on the IV bag connected to the IV pump and the observed infusion setting on the IV flow pump did not match.


An observation was made on 6/19/17 at 2:53 PM and a review of the medical record for Patient #11 was conducted with Employee A, the primary nurse for Patient #11. It was revealed that there was no order for IV continuous fluid at this time.


A second interview by phone was conducted with Employee A, the primary nurse for Patient #11, on 6/19/2017 at 4:20 PM, the Assistant Director of Nursing (ADON) was also present during the interview with Employee A, and she was asked about the IV infusion for Patient #11. Employee A stated, "I called the attending Physician and spoke to her and she is not comfortable with IV running through that port. She does not think that it was her service that the nurse talked to at the time. Yes, there was an order running of D5 ½ normal saline that was supposed to be at 50 milliliters an hour that was discontinued; but the fluid was turned down to10 milliliters an hour."


An interview was conducted with the ADON on 6/19/2017 at 4:25 PM about Patient #11 and the interview with Employee A, RN. The ADON confirmed that "there should be an order for IV fluids running and this should have been addressed."


A review of Patient #11's printed orders and Medication Administration Record (MAR) for continuous infusions revealed that Dextrose 5% 0.45% saline 1,000 ML was discontinued on 6/18/17 at 4:49 PM. This was also confirmed by the ADON on 6/19/17 at 4:20 PM, that "if there is an IV infusion running, there should be an order for the infusion."

Based on observation, interview and record review, the facility failed to ensure that drugs were administered by order of a physician or other qualified practitioner for 1 (Patient #11) out of 11 sampled patients for an IV infusion of Dextrose 5% 1/2 normal saline, which was observed administered without an order.


The findings include:


An observation was made on 6/19/17 at 2:53 PM while conducting an interview with sampled Patient #11. The observation was of an IV pump turned on, connected to the port for Patient #11 and was observed infusing at 10 milliliters an hour. The documented infusion rate on the IV bag connected to the IV pump and the observed infusion setting on the IV flow pump did not match.


An interview was conducted with Employee A, primary nurse for Patient #11 on 6/19/17 at 3:09 PM, at which time she confirmed that the IV solution for Patient #11 was running all day. She stated that during shift change, it has been reported to her that it was normal saline and should be at 20 milliliters an hour to keep the vein open (KVO).


Based on observation on 6/19/17 at 2:53 PM, and a review of the medical record for Patient #11 with Employee A, the IV fluid that was observed running at the time is not a physician ordered continuous infusion.


A second interview by phone was conducted with Employee A on 6/19/2017 at 4:20 PM. The Assistant Director of Nursing (ADON) was also present during the interview and Employee A was asked about the IV infusion for Patient #11 and she stated, "I called the Attending and spoke to her and she is not comfortable with IV running through that port. She does not think that it was her service that the nurse talked to at the time. Yes, there was an order running of D5 ½ normal saline that was supposed to be at 50 milliliters an hour that was discontinued; but the fluid was turned down to 10 milliliters an hour."


An interview was conducted with the ADON on 6/19/2017 at 4:25 PM about Patient #11, and the interview with Employee A, and she confirmed that there should be an order for IV fluids running and this should have been addressed."


A review of Patient #11's printed orders and Medication Administration Record (MAR) for continuous infusions revealed that Dextrose 5% 0.45% saline 1,000 ML was discontinued on 6/18/17 at 4:49 PM. This was confirmed by the ADON on 6/19/17 at 4:20 PM; that if there was an IV infusion running, there should be an order for the infusion.


A review of the facility provided IV therapy protocol reads that Keep Vein Open (KVO) rate is 20 milliliters an hour.