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Based on observation of Intravenous (IV) insertion, medical record review, review of facility policies and staff interviews, the Critical Access Hospital (CAH) failed to follow standards of practice for IV insertion for 1 (Patient 20) of 1 patients observed. The facility also failed to confirm the placement of a Peripherally Inserted Central Catheter (PICC) for 1 (Patient 35) of 1 record reviewed of patients with PICC lines and failed to perform initial and weekly PICC site measurements to ensure proper placement per facility policy. This failed practice had the potential to affect all patients of the CAH with IV insertions, and receiving IV medications per PICC line. The CAH reported a census of 206 patients and 842 emergency room visits for the fiscal year ending 2024.

Findings are:

A. Observation of IV insertion (4/28/25 at 3:52 PM) without observing hand hygiene being completed, RN-A opened an IV start kit and placed supplies on Patient 20's jeans soiled with mud and grease and the gurney (hospital bed). RN-A placed tape strips on edge of bedside tray table then completed a 5 second scrub with a Chloroprep pad to patient's right wrist. RN-A palpated the right wrist without changing gloves. RN-A then changed IV site prep locations to the right arm. With the same visibly brown discolored Chloroprep pad, RN-A skin prepped the right arm. RN-A inserted the IV needle with catheter and removed the needle and drew blood from catheter hub using a 10 milliliter (ml) syringe for lab samples. The syringe full of blood was placed on the gurney with no protective cap on, then a vacutainer (used to transport blood to lab tubes) was placed on the end of syringe of blood to transfer to lab tubes. RN-A placed a 10 ml saline flush (used to clear IV lines) syringe without protective cap in place, exposing syringe tip to mud and grease on jean surface. RN-A then took two pieces of tape that were attached to the bedside table to secure the IV catheter at the insertion site. RN-A received a verbal order to start fluids and obtained a 1000 ml bag of normal saline. RN-A spiked the IV bag, and primed IV tubing (process of running fluids thru IV tubing) tapped all the ports on the side of the IV pump. RN-A attached tubing to Patient 20's IV in the right wrist without gloves or performing hand hygiene.

-Review of Patient 20's medical record (4/28/25 at 3:40 PM) revealed the patient entered the emergency room (ER) with a complaint of chest pain. The physician note revealed the patient had an elevated heart rate and was in Atrial Fibrillation (A-Fib, a condition where the upper chambers of the heart beat irregularly and rapidly).

-Review of policy titled Peripheral IV (undated) stated "Aseptic [free from contamination] technique and universal precautions shall be maintained during IV insertion. Perform proper hand hygiene prior to insertion."

-Interview with Nurse Manager (4/30/2025 at 3:00 PM) confirmed RN-A failed to follow the policy for the above patient observed. The Nurse Manager also verbalized RN-A should have placed a disposable pad for the IV supplies instead of placing supplies on soiled patient jeans or the gurney.

-Interview with RN-A (5/1/2025 at 9:40 AM) confirmed [gender] failed to follow policy for Patient 20, confirming the IV start kit supplies were placed on a dirty surface. RN-A also confirmed the Chloroprep wipe was reused and dirty from the 1st cleansing of the right wrist and was re-used on the right arm site. RN-A stated the syringe filled with blood should not have been placed on the gurney without a cap in place. RN-A additionally stated the 10 ml normal saline flush should have been left with cap in place until ready for use.


B. Review of Patient 35's swing bed medical record (3/06-3/20/25) revealed the patient was admitted from an acute care facility on 3/06/2025 due to a prosthetic joint infection to left knee for strengthening and IV antibiotics.

-Review of Patient 35's medical record from the acute care facility revealed PICC line was placed to the right brachial ( blood vessel in upper arm) on 2/13/2025. Review of documentation from the acute care facility revealed the PICC line was a French size 5, Length of line inserted 45 centimeter (cm) and was verified by blood return, X-ray; Ultrasound. Review of current PICC documentation revealed facility did not verify placement of the PICC line prior to use with absence of X-ray confirmation and absence of measurements taken on admission. Documentation also revealed the facility did not measure the external length or the circumference of the PICC line site during the patients 14 day stay.

-Review of policy and procedure titled Central Vascular Access Device (CVAD) Tip Location (undated) stated the following:
"1. Assess the catheter tip position when a patient is transferred from an external health care facility; if all the follow criteria are met, it is appropriate to use the catheter without addition tip confirmation:
2. Documentation exists confirming catheter tip position at the CAJ (cavo-atrial junction, referring to heart vessel placement) on insertion.
3. Ability to aspirate blood and flush the catheter without resistance.
4. External catheter length remains the same as documented upon insertion.
5. When any of these criteria are not met, catheter tip placement should be confirmed with a chest radiograph."

- Review of policy and procedure titled Vascular Access device Assessment, Care, and Dressing Changes (undated)... "Measure the external CVAD length if applicable. Measure circumference of extremity and compare to baseline measurement."

-Interview with Nurse Manager (5/01/2025 at 9:20 AM) confirmed PICC placement was never verified per policy on admission and no measurements were documented during the 14 days of IV antibiotic administration.

Based on medical record review, observation of administration of Intravenous (IV) medication, review of policies and procedures, and facility staff interviews, the Critical Access Hospital (CAH) staff failed to administer medications with a current physician order and failed to take prescribed vital signs prior to adjusting a cardiac medication (medications affecting the heartrate, heart rhythm and blood pressure) drip rate for 1 (Patient 20) of 2 patients observed. This failed practice had the potential to affect all patients of the CAH receiving cardiac medications in IV form. The CAH reported during the previous fiscal year caring for 206 patients and 842 emergency room visits.

Findings are:

A. Review of Patient 20's medical record (4/28-4/29/25) revealed the patient entered the emergency room with a complaint of chest pain. The physician note revealed the patient had an elevated heart rate and was in Atrial Fibrillation (A-Fib, a condition where the upper chambers of the heart beat irregularly and rapidly). Patient 20 then was admitted to the hospital as an observation patient.

- Observation of Registered Nurse (RN)-B (4/29/2025 9:30 AM to 9:50 AM) administering oral and IV medications revealed the Registered Pharmacist handing off a pre-mixed bag of Diltiazem (a medication used to restore heart to normal rhythm, lower blood pressure and lower heart rate) to RN-B. The label on the bag stated "Diltiazem 125 milligrams (mg)/100 milliliter (ml) titrate according to protocol". RN-B began the medication pass by administering oral Metoprolol (a medication used to treat chest pain, lower blood pressure and lower heart rate) Extended Release 25 mg tablet and Xarelto (a blood thinner) 2.5 mg, 2 tablets. RN-B observed not taking vital signs prior to medication administration, documentation revealed last set of vital signs blood pressure (BP) 135/85 (4/29/25 at 7:32 AM) . RN-B placed the IV pump on hold, took the new Diltiazem premixed bag and scanned it and the patient hospital identification band, removed the empty bag from the tubing and spiked a new bag and hung it on the IV pole. The rate was running at 15 mg/hour. At 9:48 AM RN-B changed the administration rate setting on the pump to 12 mg/hour and resumed the infusion to the patient, there was no current order in the electronic administration record (EMAR) for 12 mg/hr medication rate. The current order in the EMAR stated "Infuse per protocol. Initial Rate 5 mg/hr, Titrate 1 mg/hr, max dose 15 mg/hr. Objective: <115 bpm (beats per minute), > 90/60 [BP]. Administer oral medication 30 minutes prior to discontinuing IV drip". RN-B was observed not to verify medication to current order in EMAR.

-Review of nursing documentation for Diltiazem titration on 4/28/2025 revealed the following:
-5:50 PM-start of the Diltiazem drip, no BP
-7:50 PM-dose increased to 10 mg/hr, no BP
-8:05 PM-dose increased to 11 mg/hr, no BP
-8:20 PM-dose increased to 12 mg/hr, no BP
-9:30 PM-dose increased to 14 mg/hr, no BP
-10:30 PM-dose increased to 15 mg/hr, no BP

- Review of Patient 20's medical record EMAR (4/29/25 at 10:20 AM) revealed a late entry order by the Registered Pharmacist (4/29/25 at 10:14 AM) stated "Administer Metoprolol ER then taper Diltiazem, reduce Diltiazem rate by 3 mg/hr every 15 minutes. Contact the provider if the heart rate goes above 100 bpm".

B. Review of the policy and procedure titled High Risk Medications (undated)..."The committee will take medications that require special education or conditions for prescribing or administering." Diltiazem medication is on the list included in the policy as a high-risk medication.

-Review of the policy and procedure titled Order Sources (undated)..."Verbal and telephone orders are to be used only in situation to meet the urgent care needs of the patient when it is not feasible for the ordering practitioner to communicate the order in written or electronic format. These orders are allowed, however, in an effort to reduce medical errors, the use of these types of orders are discouraged and to be kept at a minimum...the recipient of a verbal or telephone order will always read back the order to."

C. Interview with RN-B (4/29/2025 at 9:45 AM) during medication administration revealed that RN-B lowered Patient 20's Diltiazem drip to 12 mg per hour based off a "verbal order" from the Registered Pharmacist. RN-B went on to say it is "per protocol." At the time of medication administration RN-B could not find an order in the EMAR for the medication rate change.

- Interview with the Nurse Manager (4/29/2025 at 1:30 PM) confirmed RN-B adjusted and administered Diltiazem IV without a current order. [gender] confirmed Patient 20's medical record review lacked documentation of BP during the titration of the Diltiazem IV drip.

- Interview with the Chief Nursing Officer (4/29/2025 at 1:41PM) confirmed RN-B administered Diltiazem IV without a current order and would expect RN-B to confirm IV medication bag matched order in EMAR.

-Interview with the Registered Pharmacist (4/30/2025 at 10:37 AM) confirmed MD-A rounded on Patient 20 at approximately 8:45 AM on 4/29/2025 and conferred with the Registered Pharmacist (RPh)for the appropriate titration off the Diltiazem drip rate. RPh and MD-A decided 3 mg increments as the patient had converted back to a normal rhythm that morning and [gender] blood pressure was stable. The RPh confirmed the physician would typically put the order into the EMAR system but that did not happen, [gender]was unaware the order was not placed in EMAR. The RPh stated the Diltiazem drip rate change was communicated verbally to RN-B when RN-B called to inform the RPh that the Diltiazem bag was running very low. The RPh mixed another bag, and hand delivered it to RN-B in Patient 20's room. The RPh confirmed the order was entered as a late entry verbal order after it was called to [gender] the new order was not in the EMAR. The RPh confirmed if the nursing staff do not have a current order in the EMAR, the RPh would expect them to call and question the order. The RPh confirmed Diltiazem is considered a high risk medication.

-Phone interview with MD-A (4/30/25 at 1:00 PM) confirmed discussing titrating Diltiazem drip with RPh and thought [gender] was placing verbal order in EMAR.