Atrium Health Navicent Hospice Pine Pointe

“Based on observations, record reviews, policy review, and staff interviews, it was determined that the interdisciplinary group failed to ensure that the plan of care addressed specific treatments and individualized interventions necessary for the palliation and management of the terminal diagnosis for two patients (P) (P#20, P#21) of 21 sampled patients reviewed for medication administration. Review of the plan of care for P#21 who was admitted to in-patient unit (IPU) on 2/20/24 with a diagnosis of cerebral infraction (decreased blood flow to brain). This surveyor completed a visit observation of P#21 at the IPU and observed patient lying in bed with eyes closed. A peripheral intravenous (IV) catheter was noted in the right lower arm and appeared to be clean and intact. Review of the plan of care lacked a physician’s order for IV insertion and also lacked any interventions or documentation for the care and maintenance of the IV catheter such as the amount and solution used to flush the IV line for patency (unobstructed access). Review of the policy titled, “;Adult IV Intravenous Infusion Therapy WI”, dated 9/27/2022 reveals: Initial Assessment: • Evaluate any existing vascular access device to differentiate type and function. Maintenance: Peripheral Access: Short Peripheral Catheters (SPCs) • Replace SPC when clinically indicated or at 7 days, whichever comes first. • Change SPC dressing when it is loose or soiled. No regular dressing changes are scheduled. Insertion Site Dressings: • Maintain a sterile, appropriately sized TSM (transparent semipermeable membrane) occlusive dressing to cover all venous access device insertion sites. Evaluation and EMR Documentation: • Assess entire infusion system(s) from the solution container to the PVAD/CVAD (Peripheral Venous Access Device/ Central Venous Access Device) for integrity, patency, infusion accuracy, and expiration dates at least once every shift. • Document assessment results every shift in EMR. • Document maintenance activities when completed. The agency failed to ensure the plan of care included all pertinent interventions for the care and management of IV therapy. During an office interview on 2/28/24 at 11:00 a.m. with the IPU Manager, it was confirmed that physician’s order for IV insertion had not been obtained prior to insertion of the catheter. P#20 was admitted to the in-patient unit (IPU) on 2/21/2024 with a diagnosis of pancreatic cancer. On 2/27/2024, during an observation visit, RN BB was observed giving P#6 medicine intravenous (IV) push (IVP) (a process of introducing a medication directly into the bloodstream via the venous system) followed by a saline flush (the method of clearing intravenous lines of any medicine or other liquids to keep the lines and entry area clean and sterile). Review of clinical chart for P#20 revealed no physician orders for the insertion of the intravenous (IV) catheter, or interventions for the care and maintenance of the IV site. The records lacked MD orders for the flushing of the IV. Further review of the Coordination Notes and Visit notes failed to reveal any information on when the IV was inserted or the location of insertion. On 2/27/2024 at 10:30 a.m., an interview with RN BB confirmed no physician orders were obtained regarding the insertion, flushing or maintenance of the IV for P#20, “;We go by the standard of practice for IV site care and flushes.””

“Based on record review and staff interviews, it was determined that the Administrator failed to provide adequate oversight, and monitoring to ensure licensed staff provided services in accordance with physician’s orders as evidenced by licensed nurses administrating medications, initiating intravenous (IV) therapy without physician’s orders and not ensuring plans of care contained all the necessary services and interventions for the care for three patients (P) (P#6, P#20, P#21) of 21 sampled patients (P#1, P#2, P#3, P#4, P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18, and P#19). Findings include: 1. Review of the plan of care for P#21 reveals P#21 was admitted to in-patient unit (IPU) on 2/20/24 with a diagnosis of cerebral infarction (decreased blood flow to brain). On 2/27/2024 at 9:15 a.m., observed P#21 at the IPU lying in bed with eyes closed. A peripheral intravenous (IV) catheter was noted in the right lower arm and appeared to be clean and intact. Review of the plan of care lacked failed to reveal a physician’s order for IV insertion and also lacked any interventions or documentation for the care and maintenance of the IV catheter. 2. P#20 was admitted to the IPU on 2/21/2024 with a diagnosis of pancreatic cancer. Review records for P#20 failed to reveal physician orders for the insertion of the intravenous (IV) catheter, or interventions for the care and maintenance of the IV site. The records failed to reveal MD orders for the flushing of the IV. 3. Review of Visit Note by Registered Nurse (RN) JJ dated 1/3/2024 reveals family member of P#6 had obtained vitamin B12 injections for P#6 and requested nurse to inject. RN JJ documented “;1ML VIT B12 INJECTED INTO RT DELTOID, WITH NO DIFFICULTY.” Review of records for P#6 further reveals no physician order for injection or that a physician was called. Review of the document titled, “;Adult IV Intravenous Infusion Therapy WI,” dated 9/27/2022 reveals the following: Initial Assessment: • Evaluate any existing vascular access device to differentiate type and function. Maintenance: Peripheral Access: Short Peripheral Catheters (SPCs) • Replace SPC when clinically indicated or at 7 days, whichever comes first. • Change SPC dressing when it is loose or soiled. No regular dressing changes are scheduled. Insertion Site Dressings: • Maintain a sterile, appropriately sized TSM (transparent semipermeable membrane) occlusive dressing to cover all venous access device insertion sites. Evaluation and EMR Documentation: • Assess entire infusion system(s) from the solution container to the PVAD/CVAD (Peripheral Venous Access Device/ Central Venous Access Device) for integrity, patency, infusion accuracy, and expiration dates at least once every shift. • Document assessment results every shift in EMR. • Document maintenance activities when completed. The agency failed to ensure the plan of care included all pertinent interventions for the care and management of IV therapy and failed to follow policy to document assessment of maintenance of IV site. On 2/27/2024 at 10:30 a.m., an interview with RN BB confirmed no physician orders were obtained regarding the insertion, flushing or maintenance of the IV for P#20, “;We go by the standard of practice for IV site care and flushes.” During an interview on 2/28/24 at 10:00 a.m., an office interview with the Administrator, IPU Manager and Staff Development Coordinator it was acknowledged the clinical record lacked orders for IV insertion or interventions for the care and maintenance of the IV and the plan of care did not contain all the necessary treatments/interventions for the care of P#20 and P#21. During an office interview on 2/28/24 at 11:00 a.m. with the IPU Manager, it was confirmed that physician’s order for IV insertion had not been obtained prior to insertion of the catheter. On 2/28/2024 at 11:00 a.m., an interview with RN CC confirmed there was no physician order to give P#6 an injection.”