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DESOTO MEMORIAL HOSPITAL 900 N ROBERT AVE ARCADIA, FL 34265 Nov. 9, 2011
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview the hospital failed to follow standard nursing practice in maintaining a Nitroglycerin drip in 1 (Patient #3) of 10 patient records reviewed. The hospital failed to follow policy and procedures in establishing and discontinuing intravenous access in 6 (Patients #3, #5, #6, #7, #8, and #9) of 10 patient records reviewed.

The findings include:

1. A medical record review was completed for Patient #3. An Intensive Care Unit (ICU) standing order for a Nitroglycerin drip, dated 9/22/11, at 2100, and noted 9/22/11 at 2250, was reviewed. The order documents, "6. Monitor the vital signs every 5 min while titration is in progress, then every 30 min until stable then every hour." "9. Notify the physician of any changes in patient status."

At 2115, on 9/22/11, the nurse progress note documented, "B/P (blood pressure) 187/70 NTG (Nitroglycerin) increased to 10 mcg/min."

The next note is at 2130, on 9/22/11. Vitals are documented at that time. The nurse's note documented, "B/P 171/67. HR (heart rate) 54. NTG increased to 15 mcg/hr." After the titration of the medication vitals are recorded at 2145 and 2200. Vitals are not recorded again until 2300. The 2300 nurse progress note records that the medication was decreased to 10 mcg/hr (microgram/hour) at that time because Patient #3's B/P was 114/58.

Vitals are not recorded again until 2356. The B/P is recorded as 103/38. No titration is recorded at this time. Vitals are recorded again at 0100, on 11/23/11. The B/P is 115/45 at this time. No titration is recorded at 0100. At 0200 on 09/23/11 the nurse progress note documents, "B/P 83/44 NTG GTT placed on hold at this time." Vitals are not recorded again until one hour later at 0300. The B/P at that time is recorded as 109/56. Vitals are recorded after that at 0400, and 0600.

There is no documentation that the attending physician was every notified that the medication was placed on hold.

In reviewing the Medication Administration Record (MAR) for 9/22/11 through 9/24/11, the Nitroglycerin drip is not on the MAR until 9/24/11. There is no documentation that the medication was every discontinued or restarted after 9/23/11 at 0200.

An interview with the attending physician was conducted on 11/8/11 at 8:15 p.m. He stated, "I do not remember if I was notified that the Nitroglycerin was held."

An interview was conducted with the ICU manager, on 11/8/11 at 3:30 p.m. She acknowledged the standing orders had not been followed. She stated, "it's possible the Dr. was notified when he was rounding that morning. I can't say for sure."


2. A review of the policy of the facility for establishing and maintaining Intravenous Therapy documents: "24. Documentation- a. Document in the Meditech in the intervention section of the chart, the date, time, gauge, catheter type, zone of site, primary or saline lock, the number of attempts and by whom, site appearance, fluids used." "25. If unable to start IV after 3 attempts contact the house supervisor and/or physician for assistance."

A medical record note, dated 9/22/11, at 1443 shows a 22 gauge IV was started to the left wrist of Patient #3 in two attempts. A nursing progress note, dated 9/22/11, at 1810 documents, "NS infusing to RFA (right forearm) with no complications." There is no documentation as to when the IV in the left wrist was discontinued and why. There is no documentation when the IV in the RFA was established, by whom, or the number of attempts to obtain it. The IV assessment record dated 9/22/11 at 2156 notes, existing IV in the left anticubital. There is no documentation as to when this IV was started, by whom, or the number of attempts to obtain it. There is no documentation when the IV was discontinued in the RFA, by whom and for what reason.

A nursing progress not dated 9/23/11 at 0745 documents, "IV site has fluid from site." Another progress note dated 9/23/11 at 0815 documents, "Nurse .... attempted times two to place IV site with no luck. Pt. (patient) is refusing to have site in right arm or left anticubital." There is no documentation as to if, when and by whom the IV was discontinued from the left anticubital. A nursing progress note, dated 9/23/11, at 1900 documents, "Supervisor place IV site #24 in left pointer finger. Patient is crying uncontrollable. Ativan 0.5 mg and Ultram 50 mg given at 1930 and K pad being heated." There is no documentation of the number of attempts to obtain the IV. There is no documentation as to why Patient #3 is crying uncontrollably. The nurse progress note, dated 9/23/11, at 2030 documents, "patient is wanting to go home AMA." There is no documentation as to the reason Patient #3 is wanting to leave. The nurse progress note, dated 9/23/11, at 2100 documents, "After speaking to the house supervisor and a Spanish interpreter, the patient now wants to stay."

The nursing progress note, dated 9/24/11, documents, "IV site was removed by patient." Nurse progress note, dated 9/24/11, at 0903 documents, "patient tells this interpreter" that she does not feel safe here." There is no documentation as to why Patient #3 does not feel safe. The nurse progress note, dated 9/24/11, at 0917 documents, "interpreter here and explains AMA (against medical advice) form. Patient leaves at 0930."

Interview with Licensed Health Care Risk Manager (LHCRM) was conducted on 9/7/11 at 2:00 p.m. She confirmed here was a lack of documentation as to establishing, maintaining, and discontinuing the IV for Patient #3.

3. A review of the nursing progress note for Patient #5, dated 11/4/11, at 1445 documents, "Patient noted to have 2 #20 gauge catheters in right arm, fluid infusing in both. A nursing progress note, dated 11/4/11, at 1930 documents, "IV infiltrate noted to upper right forearm; bruising noted to site; warm compress applied." There is no documentation the IV in the right arm was ever discontinued for Patient #5.

An interview was conducted with LHCRM on 11/7/11, at 3:00 p.m. She agreed there was no documentation the IV was discontinued after being infiltrated.

4. A review of the treatment data record documenting that an IV was established to Patient #6's right anticubital in one attempt, on 10/21/11 at 0650. The nursing progress note, on 10/22/11, at 0500 documented, "patient pulled out saline lock." The nursing progress note dated 10/22/11, at 0913 documented, "#24 angio cath inserted in left hand." There is no documentation for the number of attempts to obtain the IV. The nursing progress note dated 10/24/11 at 0500 documented, "IV out."... "#22 restarted left forearm X1 attempt." The nursing progress note dated 10/24/11 at 2030 documented, "Patient has no heplock site." There is no documentation as to what happened to the heplock in Patient #6's left forearm.

The nursing progress note dated 10/28/11 at 1330 documented, "IV site to left forearm #20 on 2nd attempt .... " The nursing progress note dated 10/30/11 at 0900 records Patient #6 still had the #20 IV in his left forearm. A discharge note, dated 10/30/11, at 1400, does not record if IV was discontinued at discharge.

An interview was conducted with LHCRM, on 11/7/11, at 2:30 p.m. She acknowledged there was a lack of documentation for establishing, maintaining, and discontinuing the IV for Patient #6.

An interview was conducted with the ICU manager, on 11/7/11 at 3:00 p.m. She acknowledged there was no documentation the IV was discontinued at discharge. She stated, "The patient was a Hospice patient. He probably left with IV access. We wouldn't necessarily document if the patient left with Hospice having an IV in place."

On 11/8/11 at 3:00 p.m., Hospice was contacted. They verified that Patient #6 was received by their facility with IV access.

On 11/7/ 11 at 12:30 p.m., a interview was conducted with the Medical Surgical Manger. She acknowledged the lack of documentation for starting and discontinuing IV access for Patient #6. She stated, "I don't always document the number of attempts it takes if I get it in one attempt."

5. A review of the medical record was completed for Patient #7. According to the progress notes the initial IV was started in the Left anticubital area on 10/1/11 at 1959. On 10/2/11 at 2045 the progress note documented, "IV restarted in right hand after accidentally being removed from left forearm." There is no documentation that an IV was started in the left forearm. There is no documentation that the IV in the left anticubital was discontinued. On 10/4/11 at 1940, the staff nurse documents, "#22 to right forearm with IV infusing without complications." There is no documentation that the IV was discontinued from the right hand and why. There is no documentation as to number of attempts to obtain IV to right forearm.

On 10/6/11 at 2005, the nurses progress note documented, "IV site removed from the left anticubital and fluids discontinued." There is no previous documentation the IV in the right forearm was removed. There is no documentation as to when the IV in the left anticubital was started or the number of attempts it took to obtain it.

On 10/7/11 at 0615, the progress note documented, "IV infusing well." There is no documentation as to when, were, or how many attempts it took to obtain this site. The progress note dated 10/7/11 at 1215 documented, No IV access at this time. There is no documentation as to where the IV was removed from or if the cannula was intact.

An interview was conducted with the LHCRM on 11/7/11 at 11:30 a.m. She acknowledged the lack of documentation for starting and discontinuing IV access on Patient #7.

6. A medical record review was conducted for Patient # 8. The record documented an IV was established in the right anticubital on 9/16/11 at 1110. On 9/19/11 at 2000, the staff RN records Patient #8 has a heplock in the left forearm and a IV infusing in the right anticubital. There is no documentation as to when the heplock in the left forearm was established, or how many attempts it took to obtain it.

On 9/20/11 at 1236 the nursing progress note documented, "IV site discontinued, catheter intact." There is no documentation as to which access was discontinued. There is no documentation that both IV's were discontinued.

An interview was conducted with the LHCRM on 11/8/11 at 2:35 p.m. She acknowledged there was a lack of documentation for starting and discontinuing IV access for Patient #8.

7. A review of the medical record for Patient #9 was completed. A nursing progress note written in the ER dated 11/5/11 at 1305 documented, "IV fluids infusing ..." There is no documentation as to who started the IV or when. There is no documentation as to the number of attempts it took to obtain it.

A nursing progress note written 11/6/11 at 0100 documented "Normal saline infusing at 125 cc/hr to left anticubital." There is no documentation that an IV was started in the left anticubital. There is no documentation as to the number of attempts it took to obtain the IV site. The same nurse writes another progress note at 0300 on 11/6/11 which documented "normal saline infusing at 125 cc/hr to right anticubital IV." There is no documentation that another IV was started in the right anticubital. There is no reason given for starting of another IV, or the number of attempts it took to obtain the IV access.

An interview was conducted with the LHCRM on 11/8/11 at 12:30 p.m. She stated, "it's clear that we have a problem and we need to do some teaching on documentation."