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BAPTIST MEDICAL CENTER 111 DALLAS STREET SAN ANTONIO, TX 78205 Jan. 6, 2016
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review the facility ' s nursing staff failed to implement facility policies in order to control the associated risks of infections and complications for patients receiving intravenous therapy. Nursing staff failed to replace peripheral intravenous (IV) catheters to another site every 96 hours in accordance with the facility ' s policy for 1 of 1 patient (Patient #1) who filed a specific formal complaint, and for 2 of 2 current inpatient ' s reviewed on 01/06/16 (Patient ' s #2, and #3).

On 07/19/15, Patient #1 ' s IV (inserted 07/14/15) " infiltrated " (IV catheter is dislodged and fluid infuses into the tissue). On 07/23/15 Patient #1 was readmitted to the facility with a Pulmonary Embolism (the sudden blockage of a major blood vessel/artery in the lung, usually by a blood clot), and on 07/26/15 Patient #1 had " thrombus " (blood clot) within the superficial right cephalic vein.

Findings included:

Record review of the facility ' s nursing policy titled, " Intravenous Therapy in Adults " last reviewed 10/2012 revealed the facility adhered to the Centers for Disease Control (CDC) and Prevention recommended for frequency of replacements for peripheral venous catheters, dressings, administration sets and fluids. Further review of the policy revealed, " Peripheral venous catheters are replaced and the site rotated to a new more proximal site every 96 hours. " Procedures included replace the transparent IV dressing when the IV site is changed, or when the dressing becomes damp, loosed or soiled. Label the dressing with the date and size of catheter inserted, and the date dressing changed. Nurse changing the dressing should initial the label.

Patient #1

Review of Patient #1 ' s formal complaint letter dated 09/28/15 directed to the facility and filed as a formal complaint to the state regulatory agency revealed the following:
On 07/14/15 Patient #1 was hospitalized , diagnosed with diverticulitis, and discharged home on 07/20/15. On 07/23/15 Patient #1 was readmitted to the facility and diagnosed with blood clots to his arm and chest. Patient #1 alleged his IV placed in his arm on 07/14/15 from his first admission; infiltrated and created severe pain in his arm. Patient #1 stated the IV was replaced after he repeatedly called the nurse indicating the IV was leaking. Patient #1 stated protocol for IV placement was to be 3 to 4 days with the same IV.

Interview on 01/04/16 at 2:30 PM with Patient #1 revealed he was admitted to the facility on [DATE] and an IV was placed in his right arm. Patient #1 stated on 07/19/15 his IV " blew up in arm " (infiltrated) and was leaking all over on his bed. Patient #1 stated that he had to notify the nursing staff of his IV infiltrating and then it was moved to his left arm. Patient #1 stated he was discharged on [DATE], went back to work, and then 24 hours later he felt pain in his arm that was traveling; up his arm, to his neck, and to his chest. Patient #1 stated he returned to the facility on [DATE] where he was readmitted with a pulmonary embolism, and blood clots. Patient #1 believed that his IV infiltration caused his PE and blood clot to his arm. Patient #1 stated the facility nursing staff was neglectful in that they did not change his IV and move it as required every 3-4 days.

Review of Patient #1 ' s medical records revealed the following:

Patient #1 was admitted to the facility on [DATE] with diagnosis of diverticulitis. Patient #1 had a peripheral IV catheter placed while in the Emergency Department (ED) on 07/14/15 at 21:19 with IV started; saline lock. Review of Patient #1 ' s Adult Assessment Flowsheet dated 07/15/15 revealed the IV was placed in the right antecubital (region of the arm in front of the elbow) with a # 20 gauge catheter.

Review of Patient #1 ' s nursing flowsheet dated 07/18/15 revealed at 09:00 Patient #1 ' s IV #1, was intact and dry. Further review of the nursing flowsheet dated 07/19/15 at 00:09 revealed Patient #1 ' s IV #1 was " leaking " and " erythema " (redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection). Patient #1 then had IV#2 inserted in his Left forearm (over 96 hours).

Review of Patient #1 ' s Admission Record revealed he was re-admitted to the facility on [DATE] with an acute PE. Review of Physician ' s A Progress Record dated 07/27/15 at 13:45 revealed Patient found to have arm DVT (Deep Vein Thrombosis). " Suspect it could be related to prior (sic) line from previous hospital admission. " Right arm minimal edema.

Review of Patient #1 ' s upper extremity sonographic evaluation of the deep veins dated 07/26/15 revealed no sonographic evidence for DVT of the right upper extremity. There is however thrombus seen within the superficial right cephalic vein.

Review of Patient #1 ' s nursing assessment flowsheet dated 07/26/15 at 21:31 revealed the Registered Nurse (RN) A documented patient (pt.) was worried that he would develop a clot at the end of his saline lock. Reminded pt. that he is on blood thinners to help prevent coagulation. Pt. stated he would be more comfortable with the IV out. Informed pt. that if he stays in the hospital the IV site would need to change at that time because the protocol for site change is every 4 days. Pt. states that the IV that was in his right antecubital (AC) during his prior visit was in for 6-7 days and following that IV discontinuation, he began to have pain to his right upper arm which traveled to his shoulder. Pt states that he wonders if that is where his prior clot came from and reiterated that made him concerned about his current IV because he is worried a clot may form there also. Pt. states that after his previous admission, he told his physician ' s about the arm paint but they disregarded it and proceeded to check his lower extremities on admission this stay. It wasn ' t until Saturday, 07/25/15 that Physician B gave the order to do the ultrasound of the right upper extremities. Pt very anxious that a clot will form on the current IV. Encouraged to discuss all of these issues with Physician C in the morning as he will be back on call.

Interview on 01/06/16 at 2:45 PM with the facility ' s Quality Management (QM) Director stated she had not been made aware of Patient #1 ' s complaint letter dated 09/28/15 directed to the facility. The QM Director confirmed that Patient #1 ' s records revealed IV #1 placed in his arm on 07/14/15 at 21:19 had not been replaced until 07/19/15 at 00:09 when Patient #1 ' s IV #1 was " leaking " and had " erythema; " and further confirmed it had been over 96 hours since the placement of IV #1. The QM Director further confirmed that Patient #1 was re-admitted to the facility on [DATE] with a Pulmonary Embolism, and on 07/26/15 Patient #1 had " thrombus " (blood clot) within the superficial right cephalic vein.

Patient #2

Record review of Patient #2 ' s Emergency Department (ED) Chart View revealed Patient #2 ' s IV site was started in the ED 01/02/16 at 09:24. IV Site #1 was accessed and initiated with a #20 gauge catheter in the dorsum of right arm.

Observation on 01/06/16 at 3:00 PM revealed Patient #2 in room 222 had an IV placed in his right arm that was not dated.

Review of Patient #2 ' s nursing assessment flowsheet dated 01/06/16 at 15:00 revealed the IV #1 Peripheral line had not been replaced or moved following initiation on 01/02/16 at 09:24 (over 96 hours).

Interview on 01/06/16 at 3:05 PM with Patient #2 stated his IV peripheral line had not been moved or replaced since his admission to the facility " four days " ago.

Interview on 01/06/16 at 3:10 PM with the RN Shift Supervisor stated that IV Peripheral lines were supposed to be replaced and moved " every 3 days. " RN Shift Supervisor confirmed that Patient #2 had not had his IV peripheral line replaced and moved in over 96 hours.

Patient #3

Record review of Patient #3 ' s ED Chart View revealed Patient #3 ' s IV site for #1 was started in the ED on 01/02/16 at 00:13 accessed and initiated with a #18 gauge catheter in the dorsum of right arm. IV site #2 access initiated with #18 gauge catheter in the volar aspect of the left forearm on 01/02/16 at 00:13.

Observation on 01/06/16 at 3:20 PM revealed Patient #3 in room 596 had an IV placed in his right arm and another IV placed in his left arm that were capped off (saline lock). Both IV lines in Patient #3 ' s right and left arm were dangling from his arms. The tape was not attached, loose, and soiled. There was no dates located on either of the IV ' s placed in Patient #3 ' s arms.

Review of Patient #3 ' s nursing assessment flowsheet dated 01/06/16 at 15:00 revealed the IV #1 Peripheral line had not been replaced or moved following initiation on 01/02/16 at 00:13. IV #2 Peripheral line had not been replaced or moved following initiation on 01/02/06 at 00:13 (over 96 hours).

Interview on 01/06/16 at 3:30 PM with RN-B assigned to Patient #3 stated that IV Peripheral lines were to be changed " once a week, on Wednesday ' s; or if go bad. " RN-B confirmed that Patient #3 had not had his IV peripheral lines #1 and #2 replaced or moved in over 96 hours.

During an interview on 01/06/16 at 4:30 PM with the Chief Nursing Officer (CNO) stated that IV Peripheral lines were supposed to be changed every 96 hours in accordance with the facility ' s policy and CDC guidelines. The CNO stated that IV lines could be changed sooner if the nurse assessment determines symptoms or complications associated with the inserted IV. The CNO stated it used to be procedure that on " Wednesday ' s " lines were changed, dressing changes, and labeling of IV Peripheral lines were to be completed. The CNO confirmed that the procedure of changing IV Peripheral lines on Wednesday ' s would not coincide with the policy of every 96 hours. The CNO stated that every nurse received orientation during new hire training regarding the Policy titled, " Intravenous Therapy in Adults " last reviewed 10/2012.