The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

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).

Findings:

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.