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ST VINCENT HOSPITAL 123 SUMMER STREET WORCESTER, MA 01608 Feb. 22, 2013
VIOLATION: INTEGRATION OF OUTPATIENT SERVICES Tag No: A1077
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, interviews and policy and procedure review, it was determined that Hospital Outpatient Service practices were not consistent with hospital-wide policies and procedures in relation to:
1.) 1 of 2 oxygen administrations.
2.) the documentation of 4 of 8 intravenous (IV) catheter insertions.
3.) the documentation of 5 of 8 IV catheter removals.
4.) the documentation of patient status at the conclusion of 3 of 8 outpatient visits.

Findings include:

1.) Patient #1 presented to the Non-Invasive Cardiology Department for an outpatient dobutamine stress echocardiogram (a DSE; a stress test performed using ultrasound imaging and the medication dobutamine to increase the heart rate instead of exercise) on 10/18/12.

Patient #1's 10/18/12 Dobutamine Stress Worksheet indicated his/her medical history included chronic obstructive pulmonary disease, high blood pressure, heart attack and [DIAGNOSES REDACTED](an irregular heart rhythm).

The Surveyor interviewed Patient #1's Cardiologist (Cardiologist #1) at 12:40 P.M. on 2/20/13. Cardiologist #1 said Patient #1's medical history also included [DIAGNOSES REDACTED] (heart muscle disease due to deficient blood/oxygen supply) and congestive heart failure.

The Surveyor interviewed the arrhythmia technician (tech) who escorted Patient #1 from the Non-Invasive Cardiology Waiting Area to a DSE room on 10/18/12 at 11:50 A.M. on 2/20/13. The Arrhythmia Tech said Patient #1 seemed a little winded walking to the DSE room. The Arrhythmia Tech said she asked Patient #1 if he/she was normally winded and Patient #1 replied yes and indicated that he/she used oxygen as needed. The Arrhythmia Tech said she checked Patient #1's oxygen saturation level (gives indication of the oxygen content of the blood) and when she found it to be 85 or 86% (normal is 98-100%, a level below 88% is critically low and requires immediate patient assessment and intervention), she applied nasal cannula oxygen at 2 liters/minute. The Arrhythmia Tech said she did not inform Patient #1's assigned nurse or the DSE physician of Patient #1's oxygen saturation level and her application of the oxygen because Patient #1 said he/she used oxygen at home.

Patient #1's pre-oxygen administration oxygen saturation level was not documented in his/her Outpatient Record, dated 10/18/12.

The Hospital's Respiratory Care Services Policy/Procedure titled "Oxygen Therapy" indicated: 1.) oxygen is administered by physician order, 2.) the physician order must include the oxygen delivery device type and liter flow, 3.) registered nurses (RNs) may start oxygen ordered via nasal cannula or in emergency situations via a non-rebreather (face mask), 4.) the Respiratory Therapist or RN will review the medical record and assess the patient prior to administering the oxygen therapy and 5.) oxygen therapy is discontinued by physician order or protocol.

The 10/18/12 Dobutamine Stress Worksheet indicated Patient #1 was on 2 liters of oxygen and used oxygen as needed at home. The 10/18/12 Dobutamine Stress Worksheet and DSE electrocardiogram (ECG; a record of the electrical activity of the heart) indicated Patient #1's oxygen saturation level was within normal limits throughout the DSE.

The Arrhythmia Tech said that approximately 10 minutes after the completion of the DSE, RN #1 discontinued Patient #1's IV and said Patient #1 could go home.

The 10/18/12 Dobutamine Stress Worksheet did not indicate when Patient #1's IV or oxygen therapy were discontinued or when Patient #1 left the Non-Invasive Cardiology Department. There was no evidence Patient #1's oxygen saturation level was evaluated following the discontinuation of the oxygen therapy.

Cardiologist #1 said sometime between 6:00 and 7:00 P.M. on 10/18/12, Patient #1's Significant Other telephoned and said that Patient #1 had returned home from the DSE confused.

2.) The Hospital's Nursing Policy/Procedure titled "Intravenous Therapy" indicated documentation related to all intravenous catheter insertions is to include the date, time, catheter size and site.

Four of 8 Outpatient Records of patients who had IVs inserted during the period of 10/18/12 to 2/21/13 (Patients #1, #4, #5 and #6) did not contain documentation regarding the IV insertion time, catheter size or site.

3.) The Hospital's Nursing Policy/Procedure titled "Intravenous Therapy" indicated documentation related to IV removals is to include date, time and an assessment of the (former) catheter site.

Five of 8 Outpatient Records of patients who had IVs removed during the period of 10/18/12 to 2/21/13 (Patients #1, #4, #5, #9 and #10) did not contain documentation regarding the IV removal time or an assessment of the (former) catheter site.

4.) Three of 8 Outpatient Records of patients who had outpatient procedures during the period of 10/18/12 to 2/21/13 (Patients #1, #4 and #5) did not contain documentation regarding the patient's status at the conclusion of their visit.