HospitalInspections.org

Based on interview and document review, the hospital failed to develop and update an adequate care plan for 1 of 10 patients reviewed (P1) when hospital staff inserted a midline IV catheter, but staff failed to provide dressing changes in accordance with hospital policy.

Findings include:

Medical record review revealed P1 was admitted to the hospital on 1/17/19, with diagnoses that included prosthetic valve endocarditis, congestive heart failure, atrial fibrillation, history of septic shock, and respiratory failure.

P1's peripherally inserted central catheter (PICC) procedure sheet dated 2/22/19, revealed hospital staff placed a Midline Power Wand catheter in his vein for use in IV antibiotic therapy related to pneumonia.

P1's discharge summary dated 3/9/19, revealed P1 was discharged to an cute care hospital on 3/8/19, related to new onset of shortness of breath, acute respiratory failure with hypoxia (low oxygen in the blood), and hypervolemia (fluid retention.)

A review of P1's hospital record with director of nursing (DON)-A on 4/19/19, revealed no documentation of dressing changes for P1's midline catheter dressing since the date it was placed on 2/22/19, until his discharge on 3/8/19.

During an interview on 4/18/19, at 3:40 p.m. DON-A confirmed there was no documentation of dressing changes for P1's midline IV catheter.

The policy titled Intravenous Therapy: Short Peripheral and Midline IV Therapy dated 8/1/18, revealed: under 1. Descriptions: 1. Peripheral intravenous catheters are vascular access devices whose infusion tips reside outside of the superior or inferior vena cava. 10; Dressing changes: TSM dressings every 7 days, gauze dressing every 2 days.