HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to ensure that staff were trained in first aid (the first and immediate assistance given to any person suffering from either a minor or serious illness or injury) related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for two staff (MM and CC) personnel files of three staff personnel files reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. The hospital census was 157.

Findings included:

1. Review of the undated hospital policy titled, "Use of Restraints" showed that restraint application was performed by staff who must demonstrate competency in these skills prior to applying restraints. Hospital staff members who monitor restrained patients shall be trained in the recognition of signs of physical and psychological distress, including the signs of asphyxia.

Review of the undated hospital provided document titled, "Restraint Guidelines for Care of the Patient," showed staff who care for patient's in restraints must be familiar with how to administer first aid to a patient in distress , including providing Cardiopulmonary Resuscitation (CPR), a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped. No first aid training documentation was provided by the facility.

Although requested, the hospital was unable to provide the number of restraints applied to patients in the last six months.

Review of two staff personnel records for Staff MM and Staff CC showed no restraint first aid training.

During an review of personnel files on 05/25/21 at 2:53 PM, Staff PP, Human Resources Business Partner III, stated that no first aid training documentation was present in the personnel files reviewed.

Based on observation, interview, and policy review the hospital failed to ensure staff followed the internal policy for intravenous (IV, in the vein) tubing when they failed to label and date IV tubing for nine patients (#3, #6, #10, #17, #19, #21, #22, #31 and #32) and failed to label and date IV site dressings for eight patients (#8, #9, #10, #11, #17, #19, #20 and #22) of 23 patients with IVs observed. These failures increased the risk of infection for all patients who received IV therapy. The hospital census was 157.

Findings included:

1. Review of the hospital policy titled, "Intravenous (IV, in the vein) Line Care - Adult Appendix A: Care of Adult Venous (blood) Access Devices," revised 11/01/18, showed direction for IV tubings to be labeled with the day of the week it was to be changed and that IV site dressings were to be changed every seven days and that IV site dressings were to be dated with date it was changed.

Review of the hospital's undated document titled, "Intravenous Therapy: Maintenance and Dressing Change," showed directives for staff to apply a transparent, semipermeable membrane (TSM) dressing after insertion of the IV catheter. Label the dressing per the organization's practice with the date and time of application and initial it. Replace a TSM dressing at least every five to seven days and when the dressing was not intact, loose or moist, drainage or blood under the dressing, or further assessment was needed for suspected infection or complication.

Observation on 05/24/21 at 12:38 PM on 6 South Oncology (a branch of medicine that deals with the prevention, diagnosis, and treatment of cancer)/Neurology (medical specialty dealing with the nervous system), showed Patient #3's peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) tubing was not labeled.

Observation on 05/24/21 at 2:05 PM on 5 South Medical Specialties, showed Patient #6's PICC tubing was not labeled.

During an interview on 05/24/21 at 2:27 PM, Staff K, 5 South unit manager stated that IV tubing was changed on specific days, every Sunday and Thursday, so a label was not necessary.

Observation on 05/24/21 at 12:15 PM in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Patient #8's two IV site dressings were not dated, timed or initialed.

Observation on 05/24/21 at 12:30 PM in the ICU, showed Patient #9's two IV site dressings were not dated, timed or initialed.

Observation on 05/24/21 at 12:40 PM in the ICU, showed Patient #10's IV tubing was not labeled and the IV site dressing was not dated, timed or initialed.

Observation on 05/24/21 at 12:50 PM in the ICU, showed Patient #11's two IV site dressings were not dated, timed or initialed.

Observation on 05/24/21 at 2:45 PM in the Stepdown Unit (a unit that provides an intermediate level of care between the ICU and the general medical/surgical unit), showed Patient #17's IV tubing was not labeled and the two IV site dressings were not dated, timed or initialed.

Observation on 05/25/21 at 9:00 AM in the ICU, showed Patient #19's IV tubing was not labeled and three IV site dressings were not dated, timed or initialed.

Observation on 05/25/21 at 9:40 AM in the ICU, showed Patient #20's IV site dressing was not dated, timed or initialed.

Observation on 05/25/21 at 9:50 AM in the ICU, showed Patient #21's IV tubing was not labeled.

Observation on 05/25/21 at 10:05 AM in the Stepdown Unit, showed Patient #22's IV tubing was not labeled and the IV site dressing was not dated, timed or initialed.

Observation on 05/25/21 at 9:35 AM on 4 South Cardiology (medical specialty dealing with the heart), showed Patient #31's IV tubing was not labeled.

During an interview on 05/25/21 at 9:45 AM Staff JJ, Registered Nurse, RN stated that she changed the tubing when she hung a new bag of IV fluids or she would look into the patient's record to see when the tubing had last been changed.

Observation on 05/25/21 at 10:22 AM, on 4 Central Surgical Specialties, showed Patient #32's PICC tubing was not labeled.

During an interview on 05/26/21 at 8:30 AM, Staff QQ, RN, Rehabilitation Unit (an inpatient area devoted to the rehabilitation of patients with various muscular-skeletal conditions), stated that they rarely had patients who required IV infusions but when they did, they had labels that staff entered the date that the tubing needed to be changed and placed the label onto the tubing. She stated that IV tubing was to be changed every three days.

During an interview on 05/24/21 at 12:35 PM, Staff S, RN, stated that when he inserted an IV in a patient, he documented the date, time and insertion site in the electronic health record (EHR) and does not date, time or initial the IV dressing.

During an interview on 05/25/21 at 9:55 AM, Staff CC, ICU and Stepdown Unit Supervisor, stated that her expectation of nursing staff was to date, time and initial IV site dressings after insertion and with each IV dressing change. All IV tubing should be labeled.

During an interview on 05/26/21 at 9:58 AM, Staff B, RN, Chief Nursing Officer, Chief Operating Officer stated that her expectation of nursing staff was to follow the hospital's policy and procedures regarding IV tubings and dressing sites. She stated that all polices were available online for staff access.

The nursing staff were inconsistent with the management of the patients' IV tubing and dressings on six different units when they failed to follow hospital policy.


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