HospitalInspections.org

Based on record review and staff interview, it was determined that the facility failed to prepare the patient regarding care of a newly implanted infusion port for 1 (#1) of 3 sampled patients.



Findings include:


Patient #1 was admitted to the facility on 2/14/10 with a small bowel obstruction. Review of the consultation report from a medical oncologist revealed the plan to begin chemotherapy following discharge. The medical record revealed a mediport was implanted on 2/17/10. Nursing documentation indicated that the patient was discharged on 2/19/10. Review of the "Patient Discharge Teaching" form included information on diet, activity and follow up appointments, but did not include information regarding care of the infusion port. On 3/17/10 the patient was readmitted to the facility following an episode of hypotension and seizure activity. The History and Physical report documented the site was erythematous. Blood cultures grew pseudomonas and staph epidermidis. The patient was placed on triple intravenous antibiotic therapy. During interview on 5/13/10 at approximately 2:30 p.m. the Risk Manager and Nursing Director confirmed that there was no evidence in the medical record that the patient had been provided education regarding the care of the newly implanted mediport.


6/13/10