HospitalInspections.org

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for 1 (#2) of 5 sampled patients by failing to ensure complete head to toe assessments to include vascular access devices were completed on all admissions. Findings:

Record review for patient #2 revealed he was admitted to the hospital on 08/08/17 for S/P Abdominal Trauma secondary to gunshot wound for therapy services and wound care. The patient had diagnosis of HIV, Hepatitis, Paraplegia, and a history of Bone Cancer S/P chemotherapy and radiation.

Review of the Initial Nursing Assessment dated 08/08/17 revealed cardiovascular assessment as normal and vascular access type noted as "none".

Review of the Nursing Daily Care Notes dated 08/09/17 revealed vascular access type listed as IV to right forearm. Further review of Nursing Daily Care Notes dated 08/10/17 17 revealed vascular access type listed as IV to right forearm. Nursing Daily Care Notes dated 08/11/17 revealed vascular access type listed as port a cath to right chest wall.

Review of Physicians order dated 08/11/17 revealed orders to access port a cath to right chest wall.

Interview on 10/17/17 at 12:45 p.m. with S2CNO confirmed there was no documentation to address the patients port a cath site to the right chest wall upon admission for infection, type, appearance, and was not discovered by staff until 3 days later on 08/11/17.