HospitalInspections.org

Based on a tour of the facility, review of medical records and an interview with staff, it was determined that the facility failed to ensure all hospital policies were implemented.

Findings include:

REFERENCE: Facility Policy, Subject: Intravenous Therapy: Peripheral IV Therapy Protocol, page 2 of 4, number 7 states, "...IV site will be rotated every 72 hours unless a physician's order is obtained to maintain the current site location due to limited vein access..."

1. Documentation in Medical Record #1 indicated an IV access was obtained on 10/29/12. The IV access site was documented as changed on 11/2/12. This was one day past the 72 hour limit as per policy.

2. Documentation in Medical Record #1 indicated an IV access was obtained on 11/2/12. The IV access site was documental as changed on 11/8/12. This was 3 days past the 72 hour limit as per policy.

3. A tour was conducted on 5/14/13. Three IV access sites were observed. One of the three IV sites were not changed within the 72 hour limit as per policy.

a. The patient's IV access site in room 204 was dated 5/9/13. This was two days past the 72 hour limit as per policy.

4. The above was confirmed by #2.