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Based on policy review, observation, medical record review, and staff interview, the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess intravenous (IV) access sites per policy for 4 of 6 sampled inpatients (Patient #12, #11, #8, and #7).

The findings include:

Review of current hospital policy entitled "Peripheral IV Therapy" dated 04/2011 revealed, "...V. PROCEDURE...I. Maintenance of Peripheral IV Therapy 1. The site is assessed for redness, swelling, and IV patency every 4 hours or more frequently if needed....VI. DOCUMENTATION...D. IV site condition every 4 hours...."

1. Observation during tour of the Medical Surgical Unit on 07/12/2012 at 1115 revealed Patient #12 in his room. Observation revealed a saline-locked (capped off) IV access device was located in the patient's left anticubital space (bend of elbow).

Open medical record review on 07/12/2012 at 1130 for Patient #12 revealed a 51 year-old male that was admitted on 07/08/2012 with acute pulmonary edema. Record review revealed Emergency Medical Services inserted the IV access device into the patient's left anticubital space on 07/08/2012 (no time) prior to the patient's arrival to the hospital. Record review revealed documentation nursing staff assessed the IV site on 07/08/2012 at 2330; on 07/09/2012 at 1100 (11 hours and 30 minutes since last assessment) and 1953 (8 hours and 53 minutes since last assessment); on 07/10/2012 at 0805 (12 hours and 12 minutes since last assessment); on 07/11/2012 at 0800 (23 hours and 55 minutes since last assessment) and 2030 (12 hours and 30 minutes since last assessment); and 07/12/2012 at 0800 (11 hours and 30 minutes since last assessment). Record review revealed no documentation nursing staff assessed the patient's IV access site every 4 hours.

Interview on 07/12/2012 at 1130 with the Medical Surgical Unit Nurse Manager revealed nursing staff should assess IV access sites every 4 hours and should document the assessment in the medical record. Interview confirmed there was no available documentation that nursing staff assessed the patient's IV access site every 4 hours per policy.

2. Observation during tour of the Medical Surgical Unit on 07/11/2012 at 1230 revealed Patient #11 in his room. Observation revealed a saline-locked (capped off) IV access device was located in the patient's right forearm.

Open medical record review on 07/12/2012 at 1130 for Patient #11 revealed a 34 year-old male that was admitted on 07/08/2012 with right upper quadrant pain. Record review revealed an IV access device was inserted into the patient's right anticubital space (bend of elbow) on 07/08/2012 at 2017. Further record review revealed the IV device came out or was pulled out by the patient and had to be restarted twice, the first time on 07/10/2012 at 0838 (restarted in right forearm) and the second time on 07/11/2012 at 1743 (restarted in right anticubital space). Record review revealed documentation nursing staff assessed the IV site on 07/09/2012 at 0800 and 2035 (12 hours and 35 minutes since last assessment); on 07/10/2012 at 0730 (10 hours and 55 minutes since last assessment), 0838 (after restart), 1930 (10 hours and 52 minutes since last assessment), and 2015; on 07/11/2012 at 0753 (11 hours and 38 minutes since last assessment), 1744 (after restart and 9 hours and 51 minutes since last assessment), 1955, and 1957. Record review revealed no documentation nursing staff assessed the patient's IV access site every 4 hours.

Interview on 07/12/2012 at 1130 with the Medical Surgical Unit Nurse Manager revealed nursing staff should assess IV access sites every 4 hours and should document the assessment in the medical record. Interview confirmed there was no available documentation that nursing staff assessed the patient's IV access site every 4 hours per policy.

3. Closed medical record review for Patient #8 revealed an 86 year-old female that was admitted on 02/06/2012 with altered mental status and history of congestive heart failure. Record review revealed an IV access device was inserted into the patient's left forearm on 02/06/2012 at 0021. Record review revealed on 02/07/2012 at 1800 the IV device was removed and another one inserted into the patient's right forearm. Record review revealed no reason for the change in IV sites was documented. Record review revealed documentation nursing staff assessed the IV site on 02/06/2012 at 0356, 0558, 0800, 1000, 1200, and 1920 (7 hours and 20 minutes since last assessment); on 02/07/2012 at 0700 (11 hours and 40 minutes since last assessment), 1800 (7 hours and 20 minutes since last assessment), and 1920; on 02/08/2012 at 1915 (23 hours and 55 minutes since last assessment); on 02/09/2012 at 0800 (12 hours and 45 minutes since last assessment) and 1910 (11 hours and 10 minutes since last assessment); and on 02/10/2012 at 0800 (12 hours and 50 minutes since last assessment). Record review revealed the patient was discharged to an assisted living facility on 02/10/2012 at 1445. Record review revealed no documentation the patient's IV access device was removed or assessed prior to discharge. Record review revealed no documentation nursing staff assessed the patient's IV access site every 4 hours.

Interview on 07/11/2012 at 1530 with the Medical Surgical Unit Nurse Manager revealed nursing staff should assess IV access sites every 4 hours and should document the assessment in the medical record.

Interview on 07/12/2012 at 0920 with the Director of Clinical Improvement confirmed there was no available documentation that nursing staff assessed the patient's IV access site every 4 hours per policy. Interview also confirmed there was no available documentation of whether or not the patient's IV device was removed before discharge.

4. Closed medical record review for Patient #7 revealed a 46 year-old female that was admitted on 01/31/2012 with altered mental status, left great toe cellulitis, and chronic hepatic failure secondary to chronic hepatitis. Record review revealed an IV access device was inserted into the patient's left anticubital space (bend of elbow) on 01/31/2012 at 1245. Record review revealed documentation nursing staff assessed the IV site on 01/31/2012 at 1615, 2015, 2200, and 2400; on 02/01/2012 at 0801 (8 hours and 1 minute since last assessment); on 02/02/2012 at 0800 (23 hours and 59 minutes since last assessment) and 0840; and on 02/03/2012 at 0800 (23 hours and 20 minutes since last assessment). Further record review revealed the IV device was discontinued and removed by nursing staff on 02/03/212 at 1401. Record review revealed no documentation of IV access site assessment at the time the IV access device was removed. Record review revealed no documentation nursing staff assessed the patient's IV access site every 4 hours.

Interview on 07/11/2012 at 1530 with the Medical Surgical Unit Nurse Manager revealed nursing staff should assess IV access sites every 4 hours and should document the assessment in the medical record. Interview confirmed there was no available documentation that nursing staff assessed the patient's IV access site every 4 hours per policy.

NC00079767
NC00079930