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|HCA HOUSTON HEALTHCARE SOUTHEAST||4000 SPENCER HWY PASADENA, TX 77504||March 19, 2015|
|VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS||Tag No: A0409|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility's nursing staff failed to apply label while administering Intravenous medication in 2 of 5 sampled patients
On 03/18/2015 at 01:05 p.m. patient # 2 was in room #3042, pt. was coherent with a companion at the bedside. The companion introduced herself as the daughter. The Surveyor noted a left hand Peripheral Intravenous running with 75 mls/min of Lactated Ringer ' s Solution. The Surveyor asked the patient since when it was inserted; he answered " I can ' t recall what I only know is they put this on me yesterday. "
Reviewed patient #2 medical records on 03/18/2015 revealed that patient #2 admitted to the facility on [DATE] due to Right Hip dislocation.
Interview with the Nurse Manager (1) on 03/18/2015 at 01:25 p.m., the Surveyor notified her that the PIV label for patient #2 is not identified; she said " Okay, I will make sure we will have it labeled. "
On 03/19/2015 at 10:30 a.m. the Surveyor checked patient # 2 that was in room #3042. He was awake, coherent with the same companion on 03/18/2015 companion at the bedside. The Surveyor noted a Right hand Peripheral Intravenous running with 75 mls/min of 0.45% Saline Solution. The Surveyor asked the patient since when it was inserted, he answered " I messed up with my IV last night, I guess when I was sleeping, and the night nurse inserted it here in my right hand that time. "
On 03/19/2015 at 09:45 a.m. patient # 3 was in room #3046, pt. was coherent with a companion at the bedside. The companion introduced herself as the daughter. The Surveyor noted a right forearm Peripheral Intravenous running with Magnesium and Sodium Chloride Solution. The Surveyor asked the patient since when it was inserted; he answered " They poked me like 3 times, but was it was placed when I came in. "
Reviewed patient #2 medical records on 03/19/2015 revealed that patient #3 admitted to the facility on [DATE] due to Lombago, and Acute Otitis Media.
Interview with the Staff Nurse (3) on 03/19/2015 at 10:40 a.m., the Surveyor notified her that the PIV labels for patient #2 & 3 are not identified; she said " Yes, I am going to put a label now for each of them. "
Facility Policy reviewed about Medication Administration: Intravenous Administration Guidelines Approved on 02/2015 page 1.C. " When a peripheral cannula is being used for continuous or intermittent IV infusion, it will be changed every 72 hours provided that no IV-related complications are encountered before this time. " Page 2.E.1 " All IV tubing will be labeled with a ' Day of the Week ' sticker when initiated. The ' Day of the Week ' sticker will denote the date that the tubing is to be changed. "