HospitalInspections.org

Based on observation, staff and patient interviews, and review of medical records and policies and procedures, the facility failed to ensure policies regarding intravenous (IV) care were followed during the provision of care for 3 of 17 patients (#4, #8, #12) who received IV therapy. The findings were:

1. Review of the medical record for patient #12 revealed s/he was admitted to the hospital after being transported from another facility on 4/30/12. Further review of the medical record and interviews on 7/24/12 from 3 PM to 4:10 PM with the director of nursing operations, director of quality and quality assurance analyst revealed the following information regarding the IV care for this patient:
a. The patient arrived at the hospital with IV Amiodarone (cardiac medication) infusing in his/her left wrist. The patient also had an IV saline lock in the left antecubital area. The patient was admitted to the intensive care unit (ICU) and continued to receive the IV Amiodarone.
b. On 5/1/12 at 7 AM, the saline lock in the left antecubital area was discontinued. At that time an IV was started in the patient's right wrist for continuous IV infusions and IV protonix (medication for gastric reflux disease). At 7 PM the protonix and IV fluids that had been infusing in the right wrist were moved to the left forearm and the right wrist IV was changed to a saline lock. The Amiodarone continued to infuse in the left wrist.
c. On 5/2/12 the right wrist saline lock was discontinued before the patient was moved from the ICU to the nursing care unit. Later that evening the protonix was discontinued and the left forearm IV was changed to a saline lock. The Amiodarone continued to infuse in the left wrist.
d. On 5/3/12 at 5:30 AM, the nurse noted the IV in the left wrist had infiltrated. The nurse moved the Amiodarone from the infiltrated site to the left forarm IV saline lock. Review of the 5/3/12 documentation in the nursing notes, timed 5:30 AM, showed the area of infiltration was "red swollen and tender; left upper extremity elevated and ice applied."
e. On 5/3/12 at 8 AM, the physician wrote orders for the Amiodarone to be administered orally instead of the intravenously. However, review of the record of IV infusions showed no IV fluids were administered after 4:30 AM on 5/3/12 (three and a half hours before the physician discontinued it).
f. On 5/3/12 at 3 PM, the patient received a venous upper extremity ultrasound due to swelling in his/her left arm. The findings showed "no evidence of deep venous thrombosis"... "superficial thrombophlebitis involving the cephalic vein from midportion of the upper extremity to its most distal visualized portions". On 5/4/12 the patient was discharged home with scheduled follow up appointments with the local physician.
g. Interview with the risk manager on 7/24/12 at 2:20 PM, revealed she talked with the infection control nurse on 5/30/12, reviewed the patient's medical record and determined the patient did not have an infection at the time of discharge. The risk manager also stated the patient did not have clinical signs of infection, "like an elevated white count".
h. Interview with the patient on 6/22/12 at 3:20 PM and again on 7/26/12 at 11:05 AM revealed s/he had been receiving medical care from his/her local physician for treatment of the IV infiltration area since discharge from the hospital on 5/4/12. Interview with the local physician's medical assistant on 6/20/12 at 11:15 AM confirmed the patient had been receiving antibiotic therapy for cellulitis in the left arm, at the area where the two IV sites were located during the patient's hospitalization from 4/30/12 to 5/4/12.
I. Interview with the director of quality and quality assurance analyst on 7/25/12 at 1 PM revealed they had no explanation for the decrepancies in the nursing 5/3/12 documentation that recorded the IV Amiodarone was infusing from 5:30 AM to 8 AM, but the patient had no IV intake after 4:30 AM. During the interview the two nurses also were unable to explain the nursing rationale for infusing IV fluids and two different IV medications through two different sites in the same arm for approximately twenty-eight consecutive hours, instead of placing one IV in each arm. At that time the director of quality acknowledged staff had not followed the policy regarding restarting the IV in the patient's left arm within twenty-four hours of admission.

2. Observation of patient #8 on 7/23/12 at 5:50 PM revealed s/he had an IV saline lock in the left forearm. Interview with the patient at that time revealed the IV was placed in his/her left forearm on the day of admission. Review of the medical record showed the patient was admitted on 7/17/12. This review revealed the medications that were administered through this IV site included: hydromorphine through a patient controlled analgesia pump, pre and post-operative medications, Lasix, Decadron, Zofran and Reglan. Review of the adult assessment flow sheet showed the patient had the same IV until it was discontinued on 7/23/12 when s/he was discharged after 6 PM. During an interview on 7/25/12 at12:50 PM the quality assurance analyst stated there was no documented justification for the reason the IV had remained unchanged for one hundred forty-four hours instead of being restarted within ninety-six hours according to the policy.

3. Observation of patient #4 with registered nurse (RN) #2 on 7/23/12 at 4:40 PM revealed s/he had an IV saline lock in each arm. Further observation revealed the left arm IV was dated, but the right arm IV was not. At that time, RN #2 acknowledged the missing date; and stated the policy required staff to document the start date on all IVs because it was difficult to know how long an IV had been in place without the documented date of insertion.

4. Review of the policy, "IV Starts", effective date 09/2011, showed the following guidelines for "appropriate restarting of IVs" were included in the policy:
a. All IVs started outside of the facility will be restarted within 24 hours of admission.
b. Justification for not performing ninety-six hour routine IV starts will be documented daily.
c. Dressing changes will be done every seventy-two hours and prn [as needed] and original date of insert will be indicated on dressing.