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|CLEVELAND CLINIC||9500 EUCLID AVENUE CLEVELAND, OH 44195||Dec. 12, 2013|
|VIOLATION: CONTENT OF RECORD - OTHER INFORMATION||Tag No: A0467|
|Based on patient interview, observation, medical record review and staff interview the facility failed to document the practitioner's attempts to access a patient's vein for the administration of intravenous fluids. This affected Patient # 8. The sample size was 10 patients and the current census at the time of the survey was 979.
Patient #8 was interviewed on 12/09/13 at 2:45 PM. The patient complained that during the hospital stay, two residents "jabbed" at both sides of her neck trying to start an IV (intravenous access). The patient turned head side to side to reveal the bruising on both sides of neck left behind from the unsuccessful attempts.
The medical record for Patient # 8 was reviewed on 12/10/13 and 12/11/13. There was no evidence in the patient's medical record of documentation of the unsuccessful IV attempts. Interview with Staff I on 12/11/13 at 3:00 PM revealed the hospital staff that reviewed the medical record did not find documentation of the IV attempts. Staff I assured he/ she would do further investigation and follow-up the next day.
On 12/12/13 at 8:15 AM, Staff I reported that he/she spoke with the unit manager the previous evening who spoke with one of the two residents who were caring for Patient # 8 while he/she was a patient in the Intensive Care Unit (ICU). Staff I reported the first resident unsuccessfully attempted to place an IV in the patient's left external jugular vein. A senior or third year resident unsuccessfully attempted on the patient's left external jugular vein and proceeded unsuccessfully to the right external jugular vein. Staff I stated that it was not the expectation for a doctor to document his/her attempts at IV starts.
On 12/12/13 at 10:35 AM both of the above referenced residents were interviewed. Resident # 1 (Staff K) who was the first resident to attempt the IV start in the patient's left jugular vein revealed he/she had cared for the patient since the patient had arrived to the unit from the emergency department at approximately 8:00 PM on 12/03/13. He/she could not ascertain what time the first attempt was made at the IV start, only to say, "in the early morning hours" of 12/04/13. Resident # 1 stated he/she did not document the unsuccessful attempt as he/she is unaware of any policy that directs him/her to do so.
Resident # 2 (Staff L) who is the third year resident revealed he/she explained the procedure to the patient as well as explained to the patient the need for the additional IV. When he/she was unsuccessful on the first attempt on the patient's left side, he/she asked the patient's permission to make an attempt on the right jugular vein. He/she reported the patient allowed and the attempt was made. He/she too could not ascertain the time of these attempts but narrowed the "early morning hours" to between 4:00 and 6:00 AM. Resident # 2 also stated no documentation was made as there is no policy that directs the doctor to document unsuccessful attempts at peripheral IV's.
Review of the hospital policy for the nursing institute regarding IV therapy, peripheral IV and midline catheter procedure was completed on 12/12/13. One of the key points regarding the documentation of the insertion is to "document the number of insertion attempts and locations in appropriate medical record". Interview with Staff I on 12/12/13 at 8:30 AM revealed physicians are not held to any nursing policies. At the time of the interview, Staff I could not ascertain the existence of a list of procedures a physician is to document, nor a list of procedures a physician is exempt from documenting.