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|ADVENTHEALTH ORLANDO||601 E ROLLINS ST ORLANDO, FL 32803||Feb. 18, 2014|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure nursing staff documented the removal of intravenous catheters (IV) from 2 of 5 sampled patients prior to discharge from the hospital (#2 & 6).
1. Patient #2 was admitted on [DATE] for pneumonia and discharged on [DATE]. The patient had an IV during the course of the stay, and the IV was assessed periodically and prior to medication administration.
During a phone interview on 2/18/14 at 11:55 p.m., the 6 East registered nurse (RN) manager said staff on this unit do not document removal of IVs, and unless there is a physician order for the patient to be discharged with the IV, it is assumed it is removed.
Patient #2 was returning to his country of Columbia and his own PCP at discharge. There was no documentation of the discontinuation of the IV at discharge.
2. Patient #6 was admitted on [DATE] for a right leg infection and discharged on [DATE]. The patient was discharged on [DATE] with home health care services. The patient's adult child was given instructions for follow-up care. Patient #6 had an IV and it was last assessed on 9/23/13 at 8 a.m. However, there was no documentation the IV was removed prior to discharge on 9/23/13 at 4:20 p.m.
The risk manager confirmed the findings and said the documentation did not include discontinuation of the IV for patient #2 or #6.
Review of the hospital's "Standard Operating Procedure for IV therapy: Peripheral-Care and Maintenance, Discontinuation, Complications: Adult, Pediatric and Neonatal", dated as last reviewed 11/25/13, read in part, "Documentation in the medical record shall include at least the following: a. Insertion date and time; b. insertion site location; c. catheter type, gauge, length, and size inserted; d. ongoing monitoring and assessment; e. date and time discontinued; and f. site assessment when discontinued.