HospitalInspections.org

The CONDITION of Physical Environment is NOT MET.
Based on the Life Safety Code survey conducted 01/25/11 thru 01/27/11 the Condition of Physical Environment, Safety from Fire is NOT MET in regard to doors not latching properly, lack of signage for exit access at stairwells, lack of documentation of fire drills, improper placement of smoke detectors, penetrations in smoke barriers and dirty/obstructed sprinkler heads. This would affect all 44 patients and staff at all 3 sites.

Findings include:

Please see findings under the Life Safety Code Survey as follows:

Building #1 (Main - Fairview): K 18 - doors not latching properly; K 22 - lack of signage for exit access at stairwells; K 50 - lack of documentation of fire drills; K 130 - Improper placement of smoke detectors.

Building #2: (Huron site): K 25 - penetrations in smoke barriers; K 50 - lack of documentation of fire drills; K 62 - dirty sprinkler heads.

Building #3: (Lakewood site): K 50 - lack of documentation of fire drills; K 62 - obstructed sprinkler heads.

Based on medical record review, observation, policy and procedure review and staff interview, the facility failed to ensure that proper and complete restraint orders were obtained for all restraint usage. This affected 7 out of 8 patients reviewed that had restraints applied during their hospital stay. This affected Patients 3, 10, 11, 17, 18, 20 and 25.

Findings include:

The medical record for Patient 3 was reviewed on 01/25/11. The patient was admitted to the facility on 01/14/11. Restraint flowsheets documented the patient was restrained with soft limb and/or mitten restraints from 01/14/11 at 9:00 PM to 01/15/11 at 10:00 PM, from 01/17/11 at 12:00 AM to 8:00 AM, from 01/17/11 at 5:00 PM to 01/23/11 at 7:00 PM. The medical record contained a restraint order form with only a physician signature, date, and time, but lacked justification for restraint, alternative methods tried, and type of restraint ordered for the following dates: 01/14/11,01/15/11, 01/17/11, 01/19/11, 01/21/11, 01/22/11, and 01/23/11. The restraint order forms dated 01/15/11 and 01/17/11 also lacked documentation of an order time. The medical record lacked documentation of restraint order forms for 01/18/11 and 01/20/11. The above information was verified with Staff D on 01/27/11 at 11:10 AM.

The medical record for Patient 20 was reviewed on 01/27/11. The patient was admitted to the facility on 01/24/11. The medical record contained an order dated 01/25/11 for soft limb restraints, but lacked documentation of the order time. The medical record contained documentation the patient was restrained from 12:00 AM on 01/25/11 to 12:00 AM on 01/26/11. The above information was verified with Staff D on 01/27/11 at 2:38 PM


Patient #10's medical record was reviewed on Thursday, 01/27/11. The patient was admitted on 01/20/11 with diagnoses that included Acute Respiratory Failure, sepsis, Chronic Kidney disease, hypertension, Diabetes Mellitus, a right below the knee amputation and osteoporosis. On 01/26/11, at approximately 9:30 AM the patient was observed in bed with wrist restraints applied.
A review of the patient's medical record revealed that there were 5 restraint orders that were incomplete. On 01/22/11 the restraint order was not timed nor was the information required on the upper portion of the order completed. This area showed the reason for the restraint use, the type of restraint to be used, the alternatives used and the time limit. The restraint order of 01/24/11 was signed and timed for 1330 hours but the other required information was missing/incomplete. The order of 01/26/11 was timed but the other required information was missing/incomplete. The restraint order of 01/27/11 was signed but not timed. This was verified on the morning of 01/27/11 by Staff C and D.


Patient # 11's medical record was reviewed on 01/27/11. The patient was at the facility from 12/12/10 thru 12/20/10. Review of the medical record revealed that the patient's diagnoses included Lung cancer, septicemia, acute respiratory failure, pneumonitis, acute kidney failure, anoxic brain damage, pleural effusion, diabetes mellitus, hypertension and anemia. The patient had a tracheostomy and was on a vent. The medical record review revealed that the patient had been in restraints. The following was noted in regard to the restraint orders found in the medical record: on 12/12/10 the restraint order was not timed; there was an undated incomplete restraint order with a physician's signature only; on 12/13/10, 12/14/10 and 12/15/10, the orders were not timed.


Patient # 17's medical record was reviewed on 01/27/11. The patient had been in the facility from 12/02/10 thru 12/05/10. The patient was noted to have diagnoses that included respiratory failure, left temporal hemangioma, tracheostomy, bacteremia, congestive heart failure and an incision and drainage of an abscess. The patient was noted to have been in restraints on 12/04/10 and 12/05/10. The physician's order for the restraint use on 12/05/10 was not timed.


Patient # 18's medical record was reviewed on 01/27/11. The patient had been in the facility from 12/13/10 thru 12/17/10. The patient was noted to have diagnoses that included septicemia, pneumonia, heart failure, pleural effusion, acute kidney failure, chronic kidney disease and dysphagia. The patient was noted to have been in restraints during their stay and it was noted that the order for the restraint written on 12/13/10 was not timed.


Patient # 25's medical record was reviewed on 01/27/11. The patient had been in the facility from 11/15/10 thru 11/23/10. The patient was noted to have diagnoses that included: respiratory failure, sepsis, urinary tract infection, cancer of the colon, atrial fibrillation, colectomy, colostomy, ileostomy and chronic kidney disease. The patient was noted to have been in restraints during their stay and that one order for the use of the restraint dated 11/15/10 at 11:30 PM was not signed by the physician until 11/17/10 at 10:25 AM.

The above information was shared with Staff A,B, C, D, E and F on Thursday afternoon.



21893


The Restraint Policy and Procedure was reviewed on 01/27/11. The policy stated that a physician's order was required for each restraint used. The restraint order was to be documented on a Physician's Restraint Order Form, including the order time.
The restraint order form further asks for justification, type of restraint, length of time for the restraint use and alternatives to use prior to using the restraint.

Based on patient medical record review, review of the Medical Staff By-Laws and staff interview, the facility failed to ensure that History and Physical findings were documented and placed on the patient record within 24 hours of admission for 6 out of 30 patient medical records reviewed. This affected Patients # 6, 9, 19, 22, 24 and 25.

Findings include:

Patient # 9's medical record was reviewed on 01/27/11. The patient was admitted on 01/10/11. The History and Physical (H&P) was noted to have been dictated on 01/12/11.
Patient # 22's medical record was reviewed on 01/27/11. The patient was admitted on 11/29/10 at 3:55 PM. The patient's H&P was dictated on 12/01/10 at 12:37 AM.
Patient # 25's medical record was reviewed on 01/27/11. The patient was admitted on 11/15/10. The H&P was noted to have been done on 11/16, however there was no year given.


21893

The medical record for Patient #6 was reviewed on 01/26/11. The patient was admitted to the facility on 01/20/11. The medical record contained a H&P dated 01/20/11, that was not signed by the physician as of 01/26/11. This was verified by Staff D on 01/27/11 at 11:15 AM.

The medical record for Patient #19 was reviewed on 01/27/11. The patient was admitted to the facility on 01/19/11. The medical record contained a H&P dated 01/19/11, that was not signed by the physician as of 01/27/11. This was verified by Staff D on 01/27/11 at 2:38 PM.

The medical record for Patient #24 was reviewed on 01/27/11. The patient was admitted to the facility on 01/18/11. The medical record contained a H&P dated 01/18/11, that was not signed by the physician as of 01/27/11. This was verified by Staff D on 01/27/11 at 2:38 PM.

All of the above information was shared with Staff A, B, C, D, E and F on 01/27/11 afternoon.

Based on medical record review and interview the facility failed to provide wound therapy in accordance with physician orders for 4 patients out of 30 patients that were reviewed. This affected Patients #1, 101, 103 and 104. The facility had a current census of 44 patients.


Findings include:


Patient # 1's medical record was reviewed on 01/26/11. The patient was in the facility from 10/21/10 thru 10/24/10. The patient had diagnoses that included respiratory failure, malnutrition, septicemia, end stage renal disease, epilepsy, cardiovascular disease, diabetes and a tracheotomy. The patient was noted to have a physician's wound order for the patient's bilateral heels to be cleansed with normal saline, apply Algisite, an ABD pad and Kerlix on Monday, Wednesday and Friday and as needed (PRN). Upon review of the wound assessment sheets used by the facility, it was noted that the patient also had a wound to the right and left buttocks areas. The wound assessment sheet noted that the right buttocks area measured 1.2 centimeters by 1.0 centimeters by 0.1 centimeter. The left buttocks area was documented as measuring 1.0 centimeters by 1.0 centimeters by 0.1 centimeter. The wound assessment sheet revealed documentation that the areas had dressing changes done on 10/21/10 and 10/22/10. Review of the medical record further revealed that there was no physician's order for any treatment to the buttocks areas.




21521


The medical record review for Patient #104 was completed on 01/26/11. The record review revealed that the 65-year-old patient's care began at the facility on 01/06/11. The record review revealed a history and physical dated 01/07/11 that stated the patient's chief complaint was sepsis and a decubitus ulcer. A physician's order dated 01/06/11 placed the patient on bedrest.
The record review revealed a wound assessment and re-evaluation sheet that stated the patient was assessed on 01/06/11 as having a sacral wound seven centimeters long, five centimeters wide, and four centimeters deep. The wound assessment sheet stated that negative pressure wound therapy was begun on 01/06/11. (Negative pressure wound therapy is a therapeutic technique used to promote healing in acute or chronic wounds by creating sub-atmospheric pressure in the local wound environment.) The wound assessment sheet indicated that the negative pressure wound therapy dressing was changed on 01/06/11, 01/11/11, 01/12/11, 01/14/11, 01/17/11, 01/21/11, 01/24/11, and 01/26/11. The medical record review revealed that the negative pressure wound therapy was still in place at the time of the survey on 01/26/11.
The medical record review did not reveal a physician's order to treat the sacral wound with negative pressure wound therapy.
On 01/26/11 at 9:55 A.M. in an interview, Staff BB confirmed that the medical record did not contain a physician's order to treat the patient's wound with negative pressure wound therapy.

The medical record review for Patient #101 was completed on 01/26/11. The clinical record review revealed that the 53-year-old patient's care began with the facility on 01/11/11. The record review revealed a history and physical dated 01/12/11 that stated that the patient had diabetes, was paraplegic and had an infected right foot.
The record review revealed a wound assessment and reevaluation sheet that stated on 01/12/11 that the patient had a 2.5 centimeter by one centimeter wound, red and yellow in color, with a moderate amount of clear exudates. The wound assessment sheet stated the dressing was changed on 01/14/11 and 01/19/11. The record did not reveal any further measurements for this area.
The record review revealed a wound assessment and reevaluation sheet that stated on 01/12/11 the patient had a 2.5 centimeters deep wound to the left outer foot. The wound assessment sheet stated that a hydrophilic polyurethane foam dressing was applied to the wound (A hydrophilic polyurethane foam dressing provides a physical separation between the wound and external environments to assist in preventing bacterial contamination of the wound and create a moist wound environment to aid in healing.) and that the dressing was changed on 01/14/11 and 01/19/11. The record did not reveal any further measurements for this area, nor did it did reveal any physician order for the hydrophilic polyurethane foam dressings to either foot.
On 01/25/11 at 3:30 P.M. in an interview, Staff BB confirmed that there were no orders for the hydrophilic polyurethane foam dressings to the patient's feet.

The medical record review for Patient #103 was completed on 01/26/11. The clinical record review revealed the 42-year-old male was admitted to the facility on 01/06/11. The record revealed a history and physical dated 01/07/11 that stated the patient's chief complaint was a leg abscess.
The record review revealed a wound assessment and reevaluation sheet that stated on 01/06/11 the patient had a four centimeters long by nine centimeters wide by three centimeters deep wound to the neck, red in appearance, and had a moderate amount of watery drainage.
The review revealed a physician's order dated 01/08/11 that directed the staff to do wet to dry dressing changes to the patient's neck twice a day and stated "must be done."
Review of the wound assessment and reevaluation sheet revealed that the neck dressing was changed once on 01/08/11, 01/09/11, 01/10/11, 01/12/11 and 01/13/11.
The medical record review revealed another physician's order written and dated 01/13/11 directing the staff to do wet to dry dressing changes to the patient's neck twice a day.
The wound assessment and reevaluation sheet stated the neck dressing wasn't changed at all on 01/14/11 and only once on 01/15/11.
On the morning of 01/26/11, Staff BB confirmed the dressing was not changed in accordance with the physician's orders.

Based on interview and medical record review, the facility failed to keep current the nursing care plan for 13 out of 30 patients reviewed. This affected patients 1, 2, 9, 10, 11, 12, 15, 16, 17, 18, 22, 25 and 104. The facility census was 44.


Findings include:


Patient #1 was admitted to the facility from 10/21/10 thru 10/24/10. Review of the patient's medical record revealed that the patient had decubitus ulcers on the right and left buttocks and both of their heels. As part of the nursing plan of care, the patient was to be turned and repositioned at least every 2 hours. During review of the nursing documentation sheet used to indicate turns the following was noted: on 10/21/10 no turns were noted; on 10/22/10, turns were documented at 8:00 AM, 10:00 AM, 1:00 PM and 3:00 PM and none after 3:00 PM. On 10/23/10, turns were documented as follows: 7:00 AM - back, 9:00 AM - left side, 11:00 AM - right side, 1:00 PM - left side, 3:00 PM - back, 8:00 PM - back, 10:00 PM - back, 12:00 midnight - back, 2:00 AM - back, 4:00 AM - back and 6:00 AM back. On 10/24/10 no turns were marked.
Patient #2 was admitted to the facility from 10/06/10 thru 10/10/10. Review of the patient's medical record revealed that the patient had a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. During review of the nursing documentation sheet used to indicate turns the following was noted: on 10/07/10 and 10/09/10, no turns were marked.


Patient #9 was admitted to the facility on 01/10/11. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. The patient was noted to have a large sacral wound, a wound to the right outer area of the foot, the right outer area of the ankle and a large area on the left hip. During review of the nursing documentation sheet used to indicate turns the following was noted: on 01/11/11 from 3:00 PM thru 9:00 PM no turns were marked; on 01/12/11 there were no turns marked after 6:00 PM and the patient was on their back from 7:00 AM thru 5:00 PM; on 01/13/11 no turns were marked; on 01/15/11 the patient was documented as being on their back from 7:00 AM thru 7:00 PM and no turns marked after 7:00 PM; on 01/16/11 there were no turns marked from 3:00 PM thru 8:00 PM; on 01/17/11 there were no turns marked after 8:00 PM; on 01/20/11 there were no turns marked after 7:00 PM and on 01/26/11, there were no turns marked.


Patient #10 was admitted to the facility on 01/20/11. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. The patient was noted to have wound sites on their left stump, right heel, right hand, right great toe and the second toe on the right foot. Review of the nursing documentation sheet used to indicate turns revealed the following: on 01/21/11 there were no turns documented from 2:00 PM thru 7:00 PM; on 01/22/11 there were no turns documented from 7:00 AM thru 8:00 PM; on 01/24/11 there were no turns documented from 2:00 PM thru 8:00 PM and on 01/25/11 there were no turns documented from 1:00 PM thru 12:00 midnight.


Patient #11 was admitted to the facility from 12/12/10 thru 12/20/10. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. The patient was noted to have also needed the use of restraints during their admission. Review of the nursing documentation sheet used to indicate turns revealed the following: on 12/13/10 from 7:00 AM thru 6:00 PM, no turns were marked; on 12/14/10 there were no turns marked after 6:00 PM; on 12/18/10 there were no turns marked from 7:00 AM thru 7:00 PM; and on 12/20/10 no turns were marked at all.


Patient #12 was admitted to the facility from 10/15/10 thru 10/21/10. Review of the patient's medical record noted that on 10/15/10, 10/16/10 and 10/17/10 the patient was able to turn themselves. Then on 10/18/10 the patient was being turned but there was no documentation of the turns or an explanation as to why there were no turns from 2:00 PM thru 9:00 PM; on 10/19/10 there was no documentation of turns from 7:00 AM thru 2:00 PM and from 4:00 PM thru 8:00 PM.


Patient #15 was admitted to the facility from 10/06/10 thru 10/08/10. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. Review of the nursing documentation sheet used to indicate turns revealed the following: on 10/07/10 no turns were marked from 3:00 PM thru 7:00 PM; on 10/08/10 turns were marked from 10:00 AM thru 2:00 PM only.


Patient # 16 was admitted to the facility from 10/01/10 thru 10/09/10. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. Review of the nursing documentation sheet used to indicate turns revealed the following: that up to 10/03/10 the patient was able to turn themselves during the day but needed to be turned every 2 hours during the night; on 10/04/10 there was no documentation from 3:00 PM thru 7:00 PM; on 10/05/10 there was no documentation from 7:00 AM thru 8:00 PM; and on 10/08/10 there was no documentation from 5:00 PM thru 10:00 PM.


Patient #17 was admitted to the facility from 12/02/10 thru 12/05/10. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. Review of the nursing documentation sheet used to indicate turns revealed the following: on 12/02/10 at 8:00 PM the patient was on their left side. There was no documentation after that time; on 12/03/10 there was no documentation from 10:00 AM thru 7:00 PM; on 12/04/10 turns were documented at 8:00 PM and again at 11:00 PM; on 12/05/10 there was no documentation after 8:00 AM.


Patient #18 was admitted to the facility from 12/13/10 thru 12/17/10. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. Review of the nursing documentation sheet used to indicate turns revealed the following: on 12/14/10 there was no documentation after 2:00 PM thru 12:00 Midnight; on 12/15/10 there was no documentation of turns from 3:00 PM thru 8:00 PM; on 12/16/10 there was a check mark at the 8:00 AM space with nothing further until 7:00 PM; on 12/17/10 there were no turns documented only 2 sets of vital signs at 8:00 AM and 3:00 PM.


Patient # 22 was admitted to the facility from 11/29/10 thru 12/07/10. Review of the patient's medical record revealed that there was a nursing care plan calling for the patient to be turned and repositioned at least every 2 hours. Review of the nursing documentation sheet used to indicate turns revealed the following: on 11/30/10 there were no turns marked from 7:00 AM thru 8:00 PM; on 12/04/10 at 8:00 AM it was recorded that the patient was on their back. Nothing further was recorded until 3:00 PM which also noted that the patient was on their back. The next entry was not until 8:00 PM and it was marked that the patient was on their back at that time as well as at 10:00 PM. The next times documentation was seen was at 1:00 AM, 3:00 AM and 5:00 AM all marked that the patient was on their back; on 12/05/10 the documentation was only marked at 8:00 AM and 3:00 PM and both stated the patient was on their back; on 12/06/10 the documentation from 7:00 AM thru 5:00 PM stated that the patient was a "self turn" with no further documentation; on 12/07/10 the documentation shows that the patient was turned from 7:00 AM thru 2:00 PM.


Patient # 25 was admitted to the facility from 11/15/10 thru 11/23/10. Review of the patient's medical record revealed that there was a nursing care plan requesting the patient to be turned and repositioned at least every 2 hours. Review of the nursing documentation sheet used to indicate turns revealed the following: on 11/17/10 there was no documentation of turns from 7:00 AM thru 8:00 PM; on 11/20/10 there was no documentation after 7:00 PM; on 11/22/10 there was no documentation from 2:00 PM thru 9:00 PM and then it was documented that the patient was on their back.



21521


The medical record review for Patient #104 was completed on 01/26/11. The record review revealed the 65-year-old patient's care began at the facility on 01/06/11 and a history and physical dated 01/07/11 that stated the patient's chief complaint was sepsis and decubitus ulcer.
A physician's order dated 01/06/11 placed the patient on bedrest.
The medical record review revealed a wound assessment and re-evaluation sheet that stated the patient was assessed on 01/06/11 as having a sacral wound seven centimeters long, five centimeters wide, and four centimeters deep. The wound assessment sheet stated that negative pressure wound therapy was begun on 01/06/11. (Negative pressure wound therapy is a therapeutic technique used to promote healing in acute or chronic wounds by creating sub-atmospheric pressure in the local wound environment.) The wound assessment sheet indicated that the negative pressure wound therapy dressing was changed on 01/06/11, 01/11/11, 01/12/11, 01/14/11, 01/17/11, 01/21/11, 01/24/11 and 01/26/11. The clinical record review revealed the negative pressure wound therapy was still in place at the time of the survey on 01/26/11.
The record review did not reveal any nursing care plan in regard to preventing any further skin breakdown.
The record review revealed that there were daily nursing flow sheets that had an area to indicate on what hours the patient was turned. The nursing flow sheets for 01/21/11 and 01/24/11 did not indicate if the patient was ever turned. The nursing flow sheet for 01/25/11 did indicate where the patient had been turned but only after 2:00 P.M.
On 01/26/11 at 9:55 A.M. staff BB confirmed the clinical record did not contain a nursing care plan to address the patient's skin. "I don't see it," he/she said.

Based on medical record review and staff interview, the facility failed to ensure that all medical records were completed within 30 days of discharge from the facility. This affected a total of 38 medical records from all 3 sites. The facility census for all 3 sites was 44 at the time of the survey.


Findings include:


A review of 12 closed medical records was done. Of the 12 closed medical records 8 were noted to be incomplete/delinquent. The closed medical records that were reviewed were from discharges dated 10/01/10 thru 12/23/10.


21521


While survey the Huron site on 01/26/11 at 2:15 P.M., Staff CC presented to the surveyor a document that broke down the number of delinquent medical records for Huron. A review of the document completed on 01/26/11 revealed the facility had 21 medical records from 01/01/10 back to 08/31/10 that were delinquent.

On 01/26/11 at 2:15 P.M. in an interview, Staff CC confirmed the above delinquencies and stated he/she has notified his/her immediate supervisor, Staff B.

The above information was shared with Staff A, B, C, D, E and F on Thursday afternoon. Staff A and C stated that they had not been aware of this requirement for medical records.






21893


Staff B was interviewed on 01/27/11 at 10:25 AM. Staff B stated that there was a total of 38 medical records delinquent/incomplete after 30 days post discharge. Staff B also stated that there was no policy or procedure in place for any type of consequence to the physicians for not completing medical records within 30 days of discharge.

The delinquent record number for each site was: Lakewood - 8; Fairview - 12; Huron - 18.

Based on observations, review of documentation from the facility and staff interviews, the facility failed to ensure that they met the requirements for Life Safety from Fire for all areas of all 3 sites. This would affect all 44 patients and all staff of the 3 sites.

Findings include:

Please see findings under the Life Safety Code Survey as follows:

Building #1 (Main - Fairview): K 18 - doors not latching properly; K 22 - lack of signage for exit access at stairwells; K 50 - lack of documentation of fire drills; K 130 - Improper placement of smoke detectors.

Building #2: (Huron site): K 25 - penetrations in smoke barriers; K 50 - lack of documentation of fire drills; K 62 - dirty sprinkler heads.

Building #3: (Lakewood site): K 50 - lack of documentation of fire drills; K 62 - obstructed sprinkler heads.

Based on interview, policy review, and observation, the facility failed to follow its own policy in regards to intravenous solution infusion. This affected Patient #105. The facility census was 44.

Findings include:

The medical record review for Patient #105 was completed on 01/26/11. The record review revealed the 57-year-old patient was admitted to the facility on 01/05/11. The record review revealed a history and physical dated 01/05/11 that stated the patient's chief complaint was respiratory failure.
The medical record review revealed a physician's order dated 01/24/11 at 8:39 AM to give an antibiotic by intravenous every six hours. The record review revealed a physician's order dated 01/25/11 at 11:30 AM that stated to continue giving the antibiotic for one week.
A review of Policy #16 entitled "Intravenous Therapy; Care and Maintenance," revised 09/10, was completed on 01/26/11. The review revealed intravenous solutions "require" the use of an infusion pump if the intravenous site is positional.
On 01/25/11 at 1:55 PM, the surveyor observed the bag of antibiotic intravenous solution hanging from an intravenous pole infusing into the patient without an intravenous pump.
On 01/25/11 at 1:55 PM, in an interview, Staff Nurse D confirmed the intravenous solution was not being infused via an infusion pump because the intravenous access site was positional. He/she said the infusion pump would frequently alarm as the patient bent his/her arm, thereby occluding the flow of the solution.
On 01/26/11 at 11:30 AM Staff AA confirmed the patient's intravenous solution should have been infusing via an intravenous infusion pump.