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UNIVERSITY HOSPITAL AND MEDICAL CENTER 7201 N UNIVERSITY DR TAMARAC, FL 33321 March 6, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and clinical records reviews nursing staff failed to implement approved nursing services policy for the care of Peripheral Inserted Central Catheters (PICC), and Change in patients conditions. This failure affected 1 of 5 sampled patients (#1).

Findings include:


On 03/05/15 at 11:15 a.m. the review of a list of 10 patients with PICC lines was conducted.

On 03/05/15 at 11:40 a.m. during observation of care Patient #1 was observed to have an isolation sign on the room door. An interview was conducted with the RN Assistant Director of Nursing Services, 2nd floor in the presence of the RM at 11:41 a.m., who stated Patient
#1 is on isolation for an infection in the heel wounds. She stated he is on intravenous antibiotics via a PICC line.

On 03/05/15 at 11:45 a.m. an interview was conducted with the 2nd floor Registered Nurse (RN) regarding Patient #1 who stated Patient #1. The nurse stated, diabetic wounds and a PICC line for the administration of intravenous antibiotics; the patient is in an isolation room due to an infection of the wounds. The RN stated the wound care is done daily and the PICC line is flushed every shift to maintain patency.

On 03/05/15 at 12:31 p.m. a telephone interview was conducted with Patient #1 who confirmed he has a PICC line which he had prior to admission to the hospital. He stated he has been in the hospital for three days and they are not looking after the PICC line. He stated he was receiving intravenous antibiotics at home for an infection of his wounds.

Review of the Emergency Provider Report, dated 03/02/15 at 1633 hours by the ER physician reveal documented 'Patient presents with a PICC line to the left arm.'
Review of the Initial Adult Admission assessment dated [DATE] at 2227 completed by the RN when the patient was admitted to the 2nd floor does not document any evidence Patient #1 has a PICC line.
Review of the History & Physical completed by the attending physician dated 03/03/15 at 1225 p.m. documents Patient #1 'Apparently has a PICC line in his right forearm.'
Review of a Podiatry consult dated 03/03/15 at 1308 hours did not disclosed any documentation indicating Patient #1 has a PICC line.
Review of the Infectious Disease physician consult dated 03/04/15 at 1248 hours reveal documented, 'There is a right PICC line.'

On 03/06/15 at 12:00 p.m. the electronic medical record for Patient #1 was reviewed with the RM who after reviewing the Nursing Notes and the monitoring section where the nurses sould document the assessment of the PICC line, stated it looks like there is no documentation of the PICC line assessment. The RM stated Patient #1 was admitted with the PICC line so that is why he is not on the list of patients with PICC lines. He stated the list generated are for patients with the PICC lines that were inserted after the patients were admitted to the facility.

On 03/06/15 at 12:20 p.m. an interview was conducted with the RN Assistant Director of Nursing Services 2nd floor in the presence of the RM who stated the protocol for PICC lines is to flush the catheter with 10 cc of Normal Saline every 12 hours. She proceeded to look in the electronic medical record for Patient #1 and confirmed there is no evidence of documentation of any PICC line assessment or flushes for Patient #1. The RM stated during the review of the electronic medical record, in the daily patient assessment by the nurse every shift, under the PICC line assessment section they are attesting to doing the flush per their protocol with 10 cc of Normal saline every shift and before and after medications. However review of the PICC line assessment section in Patient #1's record is blank from the date of admission on 03/02/15 to the current date. The RM stated the saline flushes are not included in the Medication Administration Record (MAR) and maybe they should get pharmacy to add it to the MAR so the nurses have to document it is done. Further review of the MAR revealed Patient #1 was started on intravenous antibiotics on 03/04/15 with the first dose given at 1014 hours. There is no evidence of nursing documentation of any type of intravenous access for Patient #1 from admission at 1735 on 03/02/15 to the first dose of intravenous antibiotic administered at 1014 on 03/04/15.
Review of the facility PICC Policy reveal in part, 'Flush PICC catheter with 10 ml normal saline after each use and every 12 hours. The initial dressing change is done 24 hours after insertion. Dressing change should be done every seven days.
On 03/06/15 at 12:45 p.m. hard copies of Patient #1's MARs were reviewed to reveal on 03/02/15 at 2126 hours the 2nd floor RN documented under the Vancomycin 1 gram intravenous order dated 03/02/15, 'I spoke to ER nurse who stated the patient refused she will document it.' Review of the Emergency RN notes dated 03/02/15 reveals documentation of an incident occurring at 1700 hours. The notes recorded at 2203 hours document, 'Attempted to administer Vancomycin to patient as ordered. Patient refused antibiotic.'

Further review of the Nursing Notes revealed no evidence of documentation the physician was notified the patient did not receive the antibiotic as ordered.
Further review of the MAR revealed on 03/03/15 at 0917 the RN held Patient #1's Metformin (diabetic medication) with the reason documented as 'Patient not eating.' Additionally, on 03/03/15 at 1607 the RN held Patient#1's Metformin with the reason documented as 'Poor appetite'. Review of the Nurses Notes did not reveal any documentation of the patient's blood sugar prior to holding the diabetic medication. In addition there iss no evidence of documentation the RN notified the physician she was holding the diabetic medication.
On 03/06/15 at 2:50 p.m. an interview was conducted with the RN Assistant Director of Nursing Services 2nd floor, in the presence of the RM. The Assisteant Director of Nursing stated if a diabetic medication is held the physician should have been notified. After review of the electronic medical record she verified there is no documentation in the chart the RN informed the physician she held the medication. Additionally, she verified the RN did not inform the physician Patient #1 refused the intravenous Vancomycin while in the ER.
Review of the facility "Change in Patient's Condition, Notification of Physician" Policy reveal in part, 'The attending physician and appropriate consulting physician shall be notified immediately upon any significant changes in his/her patient's condition which may warrant immediate intervention or change in prescribed therapy..... The charge nurse or licensed personnel caring for the patient is responsible for notifying the attending physician and appropriate consulting physician immediately upon any significant changes in patient's condition which may warrant immediate intervention or change in present therapy.'