HospitalInspections.org

Based on policy and procedure review, medical record review, observation, and staff interview, the nursing staff failed to rotate a peripheral IV site as per hospital policy for 1 of 1 patients (#13); failed to label peripheral IV (a tube placed in a vein of the hand or arm for medication or fluid administration) sites per hospital policy for 3 of 3 patients (#13, #19, and #20); and failed to ensure an EKG (electrocardiogram) was performed as per physician's order for 1 of 3 patients (#10).

Findings include:

Review of the hospital's policy and procedure titled "IV Therapy, Initiation and Maintenance" with "Current Effective Date: 08/22/14" instructs nurses to "...Apply label to dressing stating catheter size, date, time and initials of nurse performing venipuncture (the puncture of a vein with a needle)...". Additionally, the policy states "...Peripheral IV sites are rotated every 96 hours. When clinically necessary, the catheter may be left in place longer, ...An exception note documenting rationale for not rotating is documented in the Medical Record..."

1. Open medical record review on 07/21/2015 of patient #13 revealed a 73 year old female who presented to the emergency department on 07/12/2015 with complaints of syncope (fainting or passing out) and was admitted on 07/13/2015 with a diagnosis of neutropenia (an abnormally low count of neutrophils, a type of white blood cell that helps fight off infections), syncope, and metastatic lung cancer (a cancer that has spread from the part of the body where it started (the primary site) to other parts of the body). Review of patient #13's Emergency Department notes dated 07/12/2015 1504 revealed an IV notation "...Antecubital (the area of the arm in front of the elbow) Left...Catheter size: 20g...". Further review of medical record revealed a nurse's note dated 07/19/2015 1630 "...Redness to SL (saline lock - and IV catheter used for intermittent fluid or medication administration) in LAC (left antecubital). Flushes with no issues. Pt (patient) wishes for SL to remain, does not want removed...". There is no documentation showing the physician was made aware that the IV was left in place. Record review revealed a Nurse's note on 07/22/2015 indicates left AC IV discontinued. Record review revealed patient #13's left AC IV was left in place for 10 days.

Interview with Nurse Manager (NM) #3 on 07/23/2015 revealed nursing staff should "date, time and initial" IV sites for "an easy visual to see when you have to change the site." Per policy, "Change site in four days - 96 hours." NM #3 stated the nurse would need a physician order to keep an IV in past four days. If a patient refused an IV change, "the nurse should call the doctor and obtain an order to maintain the site." NM #3 confirmed patient #13's left AC remained in place for 10 days. NM #3 also confirmed there is no documentation on 07/16/2015 (the date the site should have been changed per policy) stating why the IV was left in place.

2. Observation of patient #13 during a scheduled medication administration time revealed a 68 year old male admitted on 07/19/2015. Patient #13 had an IV in his right arm, left arm, and the right side of his neck. The IV sites did not have a label indicating the catheter size, date and time of insertion, or initials of the nurse who performed the venipunctures.

Interview with NM #3 on 07/23/2015 revealed nursing staff should "date, time and initial" IV sites for "an easy visual to see when you have to change the site."

3. Observation of patient #19 during a patient interview revealed a 73 year old female admitted on 07/13/2012. Patient #19 was noted to have an IV in her left arm. The IV site did not have a label indicating the catheter size, date and time of insertion, or initials of the nurse who performed the venipuncture.

Interview with NM #3 on 07/23/2015 revealed nursing staff should "date, time and initial" IV sites for "an easy visual to see when you have to change the site."

4. Observation of patient #20 during a patient interview revealed an 85 year old male admitted on 07/18/2015. Patient #20 had an IV in his right wrist and an IV in his left arm. The IV sites did not have a label indicating the catheter size, date and time of insertion, or initials of the nurse who performed the venipunctures.

Interview with Nurse Manager NM #3 on 07/23/2015 revealed nursing staff should "date, time and initial" IV sites for "an easy visual to see when you have to change the site."

5. Closed medical record review on 07/21/2015 of patient #10 revealed a 68 year old female admitted on 05/09/2015 with a diagnosis of Acute hypoxic (inadequate oxygen in the blood) respiratory failure likely from pneumonia (a lung infection), Bilateral pneumonia (affecting both lungs), Sepsis (a potentially life-threatening complication of an infection) secondary to pneumonia, and Hypotension (low blood pressure). Review of the RN #4's clinical notes for patient #10 revealed a nursing note dated 05/14/2015 0735 reporting complaints of chest pain and notification of the physician. Review of physician's PROGRESS NOTES dated 05/14/2015 at 0800 revealed an assessment note stating "...c/o (complaint of) chills, CP (chest pain) 3/10 intensity, SOB (shortness of breath)...stat (immediately) blood culture...ordered, EKG (electrocardiogram-a test that checks for problems with the electrical activity of the heart) ...". Further record review revealed a physician's order dated 05/14/2015 at 0830 for "...EKG 12-Lead Tracing (Named facility ED) Stat ...". Record review revealed no documentation indicating the named patient received an EKG the morning of 05/14/2015.

Interview with Administrative Staff (AS) #5 on 07/23/2015 revealed the 05/14/2015 EKG order for patient #10 was ordered incorrectly as an ED EKG. The EKG order was electronically sent to the ED and not to the inpatient EKG department. AS #5 confirmed the EKG was never performed for patient #10 on the morning of 05/14/2015. Interview confirmed the nursing staff failed to follow a physician's order for obtaining an EKG for patient #10.

Based on policy and procedure review, medical record review, and staff interviews the facility failed to reassess a patient according to hospital policy after a blood transfusion and potential transfusion reaction for 1 of 2 transfusion patients reviewed (Pt # 1).
The findings include:
Review of Hospital Policy "Blood and Blood Products Transfusion", current effective date 09/04/2014, revealed "...C. Transfusion of Blood Product:....5....a. Signs and symptoms indicative of a potential transfusion reaction are: Temperature increase of at least 2 (degrees) F (Fahrenheit)....or chills. Fever is one of the most important indicators of an adverse reaction....Example: 2 (degree) F rise in temperature....6. The transfusionist STOPS the transfusion and initiates actions listed below if a transfusion reaction is suspected....i. Stop infusion....ii. Obtain and record vital signs....x. Assess vital signs more frequently when the patient's condition is unstable. 7. Vital signs are monitored and documented until thirty (30) minutes after the completion of the transfusion....Nursing Action....Obtain vital signs (TPR (Temperature, Pulse, Respirations), BP (Blood Pressure), and pulse ox (oximetry - measure oxygen levels in blood) within 30 minutes prior to obtaining blood from Transfusion Services and starting transfusion....Obtain vital signs 15 minutes after starting transfusion. If S/S (signs/Symptoms) of reaction occurs, stop infusion. (See steps for Nursing Intervention Regarding Tranfusion Reactions.)....Takes vital signs at termination of transfusion and 25-35 minutes after completion of transfusion. ..."
Closed medical record review of Pt # 1 revealed the patient was admitted on 03/24/2015 with a diagnosis of rectal and anal hemorrhage. Review revealed a blood transfusion order on 03/30/2015. Review of "Blood Product Transfusion Record" revealed the Baseline vital signs were taken at 1220 and the T was 100.4 F, BP 150/84, P 108, R 16, and SpO2 (or pulse ox, blood oxygen saturation, normal 95-100) of 100%. At 1230, per document review, the blood was started. Further review revealed at 1245 the patient's T was 101.4, BP 173/95, P 131, R 18, SpO2 was 94%. Review revealed the transfusion was stopped. Review revealed a post-transfusion temperature of 103.1. Other vital signs were documented as BP 131/65, P 111, R 18, Pulse Ox 100%. Review did not reveal the specific time the vital signs were taken, but did reveal a Nurse signature, dated 03/30/2015 and timed 1435 (1 hour, 50 minutes after the blood was stopped). Record review did not reveal any other documentation to indicate timing of the post transfusion vital signs. Further, review revealed a vital sign flow sheet, dated 03/30/2015 at 1751, showing a Temperature of 100.6 (2 hrs, 57 min after the T of 103.1). Review did not reveal documentation that the temperature was reassessed until 1751.
Interview with Patient Care Manager (PCM) # 7, on 07/23/2015 at 1145 revealed PCM # 7 confirmed no documentation to indicate the post-transfusion vital sign check was done before 1435 and no documentation of temperature reassessment until 1751.
Interview with Administrative Staff # 2, on 07/23/2015 at 1630, confirmed policy was not followed in relation to post-transfusion vital signs or reassessment of abnormal temperature.
NC00108418, NC00107535, NC00107245, NC00107163.