HospitalInspections.org

Based on interview and document review, the facility staff failed to ensure they followed their policy(ies), protocols and job aids related to the intravenous (IV) administration of a High Alert Medications for one (1) of six (6) patients (Patient #1).

The findings include:

On 7/31/19 and 8/1/19, the medical records of Patient #1 was reviewed for outpatient (with Staff Member #5) and inpatient (with Staff Member #6) services provided.

Patient #1's outpatient medical record encounters documented the following IV dates;
"9/1/2017: 22g (gauge) IV established x 3 stick(s) right hand.
9/29/17: 22g IV established x 4 stick(s) left AC (antecubital (bend of elbow)).
10/19/2018: 22g IV established x 5 stick(s) Right AC.
2/11/2019: 22g IV established x 3 stick(s) Right Wrist by [name of provider]".
There was no indication that more than one provider attempted each IV access.

Facility Policy: Peripheral Vascular Access Device (VAD) Site Preparation and Placement Procedure, last revised on 12/5/17, documented under Precautions ..."No more than 2 attempts at short peripheral catheter placement will be made by any 1 clinician, and no more than 4 attempts per patient. Must Document all attempts."

Patient #1 was admitted to inpatient services on 1/30/18 for exacerbation of Multiple Sclerosis, chronic migraines, and fibromyalgia.
On 1/31/18, Patient #1 had a physician's order for 12.5 mg (milligrams) promethazine (Phenergan) IV injection every 8 hours.
The Phenergan carried with it the following instructions on administration: "For IV administration, dilute in at least 10 mL (milliliters) NS (normal saline). Give at a max rate of 25 mg/min (minute). Do not administer in the hand, wrist." Per facility procedure, High Alert Medication Procedure (last revision date of July 2016), promethazine (Phenergan) is a High Alert Medication. (High Alert Medications are medications that are likely to cause harm to the patient, even when used as intended.)

The Medication Administration Record (MAR) was reviewed on 8/1/19 and revealed:
Patient #1 received Phenergan IV on the following dates and times in the left antecubital:
1/31/18: 10:33 P.M.
2/1/18: 7:39 A.M., 5:03 P.M., 10:53 P.M. (The last dose on this day was given six (6) hours and fifty (50) minutes after the previous dose.)
2/2/18: 4:18 A.M. (This dose was given five (5) hours and twenty-five (25) minutes after the previous dose.)
On 2/2/18, the left antecubital IV was removed at an unknown time and for an unknown reason.
On 2/2/18 at 10:56 A.M., a new IV was placed in the left hand.
On 2/3/18 at 11:00 A.M., the IF was removed due to an infiltrate.

Phenergan was not administered the following dates and times:
2/2/18: 11:09 A.M., 7:50 P.M.
2/3/18: 4:45 A.M., 12:07 P.M.
On 2/3/18 at 12:20 P.M., a third IV was placed in the left lower arm via ultrasound guidance.

The Simple Nursing Assessment performed on 2/2/18 at 8:30 A.M. and 8:00 P.M. did not document evidence of an IV infiltration.
Nursing notes dated 2/5/18 at 8:00 A.M. document, "Left arm warm red and edematous. Patient reports previously having IV site that infiltrated. Offered warm compress. Patient refused at this time. Will continue to monitor."

Patient #1's in-patient Medical record review revealed no additional documentation related to an IV infiltration. The medical records reviewed lacked evidence that the Phenergan was diluted and given as directed by the instructions.

The outpatient medical record of Patient #1, dated 2/22/18, documented the following by Staff Member #4 (Physician), "...still has pain from the elbow proximally in the left upper extremity, then going down into the axilla....describes it as an ache, a stretched like feeling. Note that she received full strength Phenergan IV inadvertently during the recent hospitalization, felt to be the basis..."

Staff Member #4 was interviewed on 7/31/19 and stated, "I remember this incident. [She/He] was still having a lot of pain in that arm when I saw her/him. (Staff Member #4 reviewed the outpatient medical record of Patient #1). We always had a difficult time finding a vein to inject the medications. They [Staff in the inpatient setting] administered the Phenergan too quickly. It is has a great deal of venous toxicity."

The facility procedure titled High Alert Medication Procedure, with a Last Revision Date of July 2016, documented under Procedure: "Required Actions and Supplemental Guidance...Promethazine; Do not inject into small veins/hands/foot.
Dilute prior to administration.
Administer at lowest dose possible.
Utilize IV route as last resort."

The facility procedure titled Extravasation of Intravenous Medications, with a Last Revision Date of 1/26/17, documented under Procedure: "Required Action Steps: Initial management by nursing and under Supplemental Guidance:
Disconnect the IV tubing...
Estimate the amount of extravasated solution and notify the provider.
After the provider's order for antidote, refer to "RHS-CSG-Extravasation of Intravenous Medications Job Aid" for specific drug procedure and administration instructions...
Circle the affected area with a pen.
Document the following in the EMR (Electronic Medical Record):
Drug involved,
Estimated amount of drug extravasated,
IV site location,
Gauge of needle used,
Signs and symptoms noted by nurse,
Note patient complaints regarding site,
Physician notified,
Antidote and/or treatment ordered,
Continue to assess and document site regularly..."


The findings above were shared with Staff Member #7 and #8 throughout the days of the survey and on 8/1/19 at approximately 3:30 P.M.

Based on document review and interview, it was determined that the facility failed to maintain an accurate medical record for one (1) of five (5) patients' medical records reviewed (Patient #5).

The findings include:

On Thursday, August 1, 2019, the medical record of Patient #5 was reviewed with Staff Member #9. The 02/09/19 emergency department (ED) nursing assessment revealed, under the Lines, Drains, Airways, Tubes, and Wounds Properties section, documentation that Patient #5 had four (4) different peripheral intravascular (IV) lines/sites present.

IV Line #1, an 18-gauge needle, was placed in the right upper arm of Patient #5 on 12/31/2018. The facility assessment form included spaces to document who started the IV and why. There was no documentation of who started IV Line #1. Medical records reviewed lacked when IV line #1 was removed. Documentation on 02/09/2019 indicated that IV Line #1 was no longer present.

The nursing comment in the medical record reflected that IV line #2, an 18-gauge needle, was placed in the right antecubital on 02/09/2019 while Patient #5 was in the ED. The ED documentation indicated that IV line #2 was "not present in assessment".

IV Line #3, an 18-gauge needle, was placed in right wrist of Patient #5 on 02/09/2019 and removed. The medical record included a 02/13/2019 comment that stated that IV line #3 was "Not Present on Assessment".

IV Line #4, a 20-gauge needle, was placed at left hand on 02/09/2019 and removed on 02/12/2019. The nursing documentation stated that IV Line #4 was "not present in assessment".

IV Line #5, a 22-gauge IV, was placed in right hand of Patient #5 on 02/11/2019 and removed on 02/13/2019. Medical record nursing documentation included, "Patient [Patient #5] not sure who put IV in, had IV upon arrival to pre-op." It was documented that Patient #5 stated, "IV was put in last night around dinner time".

Medical record documentation related to IV site #5 lacked the number of attempts for insertion, who placed IV, patient tolerance, removal reason, and the name of person who removed the IV.


On August 1, 2019 at 11:30 a.m., Staff Member #9, assistant nurse manager, was interviewed regarding Patient #5 ' s four IV lines. Staff Member #9 revealed he/she did not know why the patient would have 4 IVs concurrently while in the emergency department.

On August 1, 2019 at 3:30 p.m., the surveyor conducted interviews with both Staff Member #7, Quality Director, and Staff Member #12, a RN and unit director, regarding patient #5 ' s IV line documentation. Both Staff Members #7 and #12 confirmed that IV lines #1, #2, #3, and #4 were not documented in the medical record as removed at the time of removal.

Staff Member #7 stated, "Comments were added for IV lines # 1- # 4 to show that the time that the IV was taken out was unknown but that there was no IV site present when the patient [Patient #5] presented to the ED." Staff member #12 stated, "Line #5 should have documentation regarding details for both placement and removal of IV lines and all five (5) IV lines should have reflected clear documentation regarding IV line placement when placed."

Facility policy procedure entitled, Peripheral Vascular Access Device (VAD) Site Preparation and Placement Procedure policy (with last revision date of 12/05/2017) as well as the Facility Job Aid Venous Access Site Care and Maintenance and Removal policy (with last revision date of 12/31/2018) were provided and reviewed on 8/1/19. These documents indicated in the peripheral catheter section, "clear and prompt documentation regarding IV line insertion and removals should be made accurately within patient medical records."

On August 1, 2019, Staff Member #7 stated, "This facility has been attempting to modify the electronic medical record (EMR) to require mandatory documentation of all lines removed prior to patient discharge. This change would prevent future patients from having open lines present following discharge within the medical record."

The findings above were shared with Staff Member #7 and #8 throughout the days of the survey and on 8/1/19 at approximately 3:30 P.M.