Aultman Hospital

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 22432 Based on record review, interview, and policy review, the facility failed to include all patients who presented at the ED for treatment on the ED log. This affected one (Patient #1) of one individual who presented at the facility on 03/30/25. The facility logged 6,566 individuals on the facility’s ED log during the month of March 2025. Finding include: Review of the municipal police department mental health reports dated 03/21/25 revealed at 12:50 AM the officers arrived at the listed address in reference to Patient #1 making suicidal statements. Patient #1 stated he was feeling depressed due to him being evicted from his residence and losing his children to his wife during their divorce. Patient #1 advised he does not have a plan to commit suicide, however, he just wants his life to end. Crisis responded on scene and recommended the individual be transported to a local behavioral hospital voluntarily for an evaluation. Patient #1 informed the officer he was diagnosed with bipolar disorder, anxiety, and depression. Patient #1 was transported to a local behavioral hospital. Review of the municipal police department mental health reports dated 03/30/25 revealed while officers were on patrol they responded to speak with Patient #1. He stated he was having mental health issues and wished to speak with someone at crisis. After going there and them not being able to help us, he wished to go to the hospital for more treatment. The officers dropped him off and he was calm and ready to get treatment. While the officer was typing up this report they got a phone call from the hospital saying they made Patient #1 mad and he was now being uncooperative with them. They wished for the police to trespass him even though he stated he was suicidal. He left the property before the officers could go back and was unable to be located at this time. Review of the hospital ED log revealed Patient #1’s name failed to appear on the ED log dated 03/30/25. Review of the hospital’s security department Incident Report, dated 03/30/25 at 10:08 PM, documented the report was filed as a remove trespasser report. The report narrative documents March 30, 2025 at 10:10 PM the local police department was bringing Patient #1 into the ED to Room 1. With some confusion, it was determined he was dropped off at the front of the ED at 10:15 PM. Patient #1 then walked to the middle of the parking lot with a suitcase and a duffle bag to smoke. Security Staff F walked out to Patient #1 and Staff G responded to the middle of the lot. Officers escorted Patient #1 into the ED front entrance to go through the weapons detection system. Patient #1 wasn’t understanding the process. Patient #1 hit on the weapons detection system. Patient #1 wouldn’t leave his luggage up front to register. The security attempted to clear his bags and were met with an uncooperative, “sarcastic” individual. He had a tin of knives and a pipe and what appeared to have been a drug substance he referred to as peanut butter and jelly. Patient #1 became argumentative and was scaring people who were coming into the ED. The ED entrance was quite busy at the time. Security Staff G stepped away to clear other customers as Patient #1 continued to argue with Security Department Staff F. Patient #1 was unwilling to part from his bags, getting more irate about his belongings, and security never made it through his second pieces of luggage. At 10:35 PM Security Department Staff G advised command to call the local police department back. Due to uncooperative and arguable manner Patient #1 presented to officers, due to the fact he had contraband and possible drugs, along with weapons and refusing to follow the process he was trespassed. He made it off property without incident. Interview with ED physician staff A on 04/29/25 at 2:02 PM revealed the ED log generated the work flow for the ED. Patients were placed on the log, triaged and seen by the physician staff on duty in order of triaged need. The log was the master keeper of all patients that presented to the ED. Physician Staff A stated unless the patient was on the log, or staff verbally inform the ED physicians and providers of a patient’s presence, the physicians have no way to know a patient needed to be seen and examined. Interview with facility Security Department Staff F on 05/01/25 at 1:27 PM stated he spoke with Patient #1. Staff F stated he didn’t recall asking Patient #1 if he needed to be seen for treatment. Interview with facility Security Department Staff G on 05/01/25 at 7:51 AM stated she spoke with Patient #1. Staff G stated she didn’t ask Patient #1 if he needed to be seen for treatment. Interview with the Director of Security on 05/05/25 at 1:35 PM verbalized it was his understanding Patient #1 presented to the facility’s ED with suicide ideation. Patient #1 was trespassed and asked to leave the facility’s premises. Interview on 05/05/25 at 2:58 PM local police department Officer J verbalized the local police department had received a call late in the evening of 03/30/25 from Patient #1 who expressed he felt suicidal. Officer J stated the patient was quite depressed and had vocalized suicidal thoughts to him and his partner. The individual requested to go to the hospital. The police officers escorted the individual to Aultman Hospital to the front ED lobby. The patient was not “pink slipped” and was a voluntary presentation. The protocol for a voluntary admission was to take individuals to the front main ED entrance. Pink slipped patients were to be taken to the back ambulance bay ED entrance and local PD officers stayed with these patients until hand off could occur with ED staff. This patient was essentially transported as a courtesy and dropped off. There was no hand off as the patient was a voluntary presentation. Review of the facility’s policy and procedure titled “EMTALA Compliance,” revised 07/16/24, directed all Aultman departments and facilities where patients may present for emergency medical treatment will maintain logs as provided in departmental policies. The log will identify the patient seeking treatment for a potential emergency medical condition and the disposition of that patient; whether the patient is admitted, discharged, stabilized, transferred or refused treatment. Under the section the EMTALA Central Log the policy states track transfers of patients with emergency medical condition, including transfers from Aultman to another acute care facility and transfer to Aultman for specialized services. Such patient logs must be retained according to Aultman Document Retention Policy for a period of at least 10 years from the date of disposition of the individual. This deficient practice was confirmed in interview with administrative Staff C on 04/29/25 at 1:38 PM.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 22432 Based on record reviews, interview, and policy review, the facility failed to provide a medical screening exam to all patients who presented to their emergency department. This affected one (Patient #1) out of 20 emergency department (ED) medical records reviewed and had the potential to affect any individuals who presented to the facility’s ED. The facility registered an average of 4,618 patients per month in the preceding six months. Findings include: Review of the municipal police department mental health reports dated 03/30/25 revealed while officers were on patrol they responded to speak with Patient #1. He stated he was having mental health issues and wished to speak with someone at crisis. After going there and them not being able to help us, he wished to go to the hospital for more treatment. The officers dropped him off and he was calm and ready to get treatment. While the officer was typing up this report they got a phone call from the hospital saying they made Patient #1 mad and he was now being uncooperative with them. They wished for the police to trespass him even though he stated he was suicidal. He left the property before the officers could go back and was unable to be located at this time. Review of the hospital ED log revealed Patient #1’s name failed to appear on the ED log dated 03/30/25. Patient #1 had no medical record for 03/30/25. Review of the Hospital’s security department Incident Report dated 03/30/25 at 10:08 PM documented the report was filed as a remove trespasser report. The report narrative documents March 30, 2025 at 10:10 PM the local police department was bringing Patient #1 into the ED to Room 1. With some confusion it was determined he was dropped off at the front of the ED at 10:15 PM. Patient #1 then walked to the middle of the parking lot with a suitcase and a duffle bag to smoke. Security Staff F walked out to Patient #1 and Staff G responded to the middle of the lot. Officers escorted Patient #1 into the ED front entrance to go through the weapons detection system. Patient #1 wasn’t understanding the process. Patient #1 hit on the weapons detection system. Patient #1 wouldn’t leave his luggage up front to register. The security attempted to clear his bags and were met with an uncooperative, “sarcastic” individual. He had a tin of knives and a pipe and what appeared to have been a drug substance he referred to as peanut butter and jelly. Patient #1 became argumentative and was scaring people who were coming into the ED. Security Staff G stepped away to clear other customers as Patient #1 continued to argue with Security Department Staff F. Patient #1 was unwilling to part from his bags, getting more irate about his belongings, and security never made it through his second pieces of luggage. At 10:35 PM Security Department Staff G advised command to call the local police department back. Due to uncooperative and arguable manner Patient #1 presented to officers, due to the fact he had contraband and possible drugs, along with weapons and refusing to follow the process he was trespassed. He made it off property without incident. Interview with ED physician staff A on 04/29/25 at 2:02 PM revealed all patients who come to the ED and desired to be seen all received a medical screening exam to determine if a medical emergency existed. Physician Staff A stated unless the patient was on the log, or staff verbally informed the ED physicians of a patient’s presence, we have no way to know a patient needed to be seen and examined. Interview with facility Security Department Staff F on 05/01/25 at 1:27 PM stated he didn’t recall asking Patient #1 if he needed to be seen for treatment. Interview with facility Security Department Staff G on 05/01/25 at 7:51 AM stated she didn’t ask Patient #1 if he needed to be seen for treatment. Interview with the Director of Security on 05/05/25 at 1:35 PM verbalized it was his understanding Patient #1 presented to the facility’s ED with suicide ideation. Patient #1 was trespassed and asked to leave the facility’s premises. Interview on 05/05/25 at 2:58 PM local police department Officer J verbalized the local police department had received a call late in the evening of 03/30/25 from Patient #1 who expressed he felt suicidal. Officer J stated the patient was quite depressed and had vocalized suicidal thoughts to him and his partner. The individual requested to go to the hospital. The police officers escorted the individual to Aultman Hospital to the front ED lobby. The patient was a voluntary presentation. The protocol for a voluntary admission was to take individuals to the front main ED entrance. This patient was essentially transported as a courtesy and dropped off. There was no hand off as the patient was a voluntary presentation. Review of the facility policy and procedure titled “EMTALA Compliance,” revised 07/16/24, directed any patient coming to Aultman Emergency Department(s) for assistance with a potential emergency medical condition will receive a medical screening by a qualified medical provider, the appropriate medical treatment to achieve stabilization and when medically necessary, or requested by the patient, transfer to another acute care facility. This deficient practice was confirmed in interview with administrative Staff C on 04/29/25 at 1:38 PM.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 44810 Based on record review, interview and policy review, the facility failed to allow two patients (Patient #1 and #8) to exercise their rights related to intravenous (IV) lines. The facility’s census was 433. Findings include: 1. Patient #1 was admitted to the hospital on 04/02/24 with abdominal pain and diarrhea. She was found to have a partially occluded thrombus in the superior mesenteric vein. She was ordered heparin (blood thinner) on 04/02/24 and had an intravenous (IV) catheter placed in the left forearm on 04/02/24 at 4:45 AM in the emergency department. She was then transferred to the fourth floor of the hospital. Patient #1 then had another IV site placed on 04/03/24 at 3:52 PM. There was an order to discontinue heparin on 04/03/24 at 4:30 PM. Both of Patient #1’s IV sites were removed on 04/04/24 at 12:29 PM. Staff M and Staff V were interviewed on 05/08/24 at 9:00 AM. They reported Patient #1 complained that the student nurse just entered her room and did not ask her for permission to have a student nurse care for her. Patient #1 also reported that another nurse came in and reported that she needed another IV site due to the heparin needing its own site. Patient #1 reported to the nurse that she wanted the nurse to check with the physician first because he was going to discontinue her heparin. The nurse left the room and the next thing she knew the student was in the room putting in another IV site. Staff J reported that she immediately called the nurse manager and informed her of the complaint while Patient #1 was still in the hospital. She reported she then informed all the appropriate managers including the nursing school liaison and they investigated. She sent the response letter with an apology for her experience. During interview on 05/08/24 at 10:01 AM, Staff J reported she had a student with her who was working her last four-hour shift of her practicum. Staff J reported that the student nurse and the LPN were assigned to Patient #1 who both had the same name. She had requested the LPN go into her room and assess whether the heparin was running into its own line. The LPN reported that the heparin was running into the line with the primary IV fluids and antibiotics running into it. Staff J reported that the facility does not have a policy on heparin running into its own line, and everything Patient #1 was receiving was compatible, but she prefers per her own professional judgement that heparin run into its own line. She reported she explained that to Patient #1 and Patient #1 expressed concerns that she would like her physician contacted first because he had spoken about discontinuing her IV heparin and starting her on oral anticoagulation due to her now tolerating foods. Staff J reported she then exited the room and paged the physician. Twenty minutes later she returned to Patient #1’s room and observed the LPN placing an IV into Patient #1’s arm and the physician had not called back yet. Staff J confirmed Patient #1 was extremely upset. The physician called back and did switch Patient #1 from IV heparin to oral anticoagulation one hour after the new IV site was inserted. She reported Patient #1 then called the operator to complain and was notified by her nurse manager that Patient #1 complained. She reported that she did go into Patient #1’s room and listened to her grievances and apologized for her care and Patient #1 did allow her to take care of her the rest of the evening until 3:00 A.M. Staff J reported no other concerns with her care the rest of the evening. 2. Patient #8 was admitted to the emergency department on 12/02/23 and was discharged on 12/03/24. Patient #8 went to the emergency department with complaints of blurred vision for more than one week. Patient #8 had not had her blood pressure medications in two to three months due to being new to the area and not establishing care with a physician. Patient #8 returned to the emergency department on 01/02/24 with left and right arm pain. She was discharged from the emergency department on 01/03/24 with a diagnosis of superficial thrombophlebitis. Patient #8 was given discharge instructions to follow up with a physician. Patient #8 was interviewed on 05/07/24 at 10:19 AM. Patient #8 reported she screamed and cried the night of 12/02/23 to have the staff remove the left arm IV site and staff would not listen to her. Patient #8 stated the facility’s staff even had an ultrasound technician come into her room and informed the staff her IV was not in place. During an interview on 05/08/24 at 8:37 AM, Staff F reported Patient #8 informed Staff F that the IV site hurt so Staff F verified it with an ultrasound machine, flushed the site with good blood return, and informed Patient #8 that the IV was in place and working properly. Staff F reported that Patient #8 never asked or demanded to have her IV site removed. Staff I was interviewed on 05/08/24 at 9:47 AM. Staff I stated that Staff F reported to Staff I that Patient #8 was complaining of the IV site hurting and Staff F had assessed it, but Patient #8 was still complaining. Staff I then went to assess the IV site himself. Staff I stated he flushed the IV site and it flushed easily and had good blood return. Staff I also reported that he used the ultrasound machine to verify the placement and it showed the IV catheter in the vein. Staff I offered a new IV site to Patient #8 and at first, Patient #8 refused but eventually did receive one. Staff I reported Patient #8 was not asking to have the IV site removed she was just complaining it hurt. Staff T was interviewed on 05/28/23 at 3:12 PM. Staff T reported Patient #8 had Patient #8’s IV site placed in the pit (up front) area of the emergency department. “When she came back to my room, she had multiple complaints about it”. Staff T and a paramedic checked it, and it was still working. Staff I looked at it and determined it was patent. Patient #8 “said that it hurt” and was concerned because nobody had ever placed an IV in that location before. The IV was in her upper arm, above the antecubital. Staff T was unable to recall if the IV was in the right or left arm. Staff T reported Staff T flushed the IV and it had no problems. “It was pulling back blood”. Staff T reported the IV site “was hurting” Patient #8. “When I flushed it, she was acting as if she was in agony, she was constantly touching at it”. Staff T reported Patient #8 was always very vocal, she never stopped even when there was nothing going through the IV. “I did not document the issues with the IV, I let my physician know”. Staff T stated Patient #8 never asked Staff T to remove the IV site. Staff T reported Patient #8 “said it hurt, and she was concerned that she never saw an IV placed there before”. “I did not remove the IV. Had she asked me to remove the IV, I would have removed the access”. Staff T stated the facility wouldn’t give up IV access until another IV site was established, unless the site was infiltrated. The facility’s Patient Right’s and Responsibilities policy (2.2, Revision 10/18/21) stated: D. Standard: Exercise of Rights 2. A patient or his/her representative has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. The facility’s Intravenous (IV) Peripheral Catheter Site Inspection, Care and Rotation policy (4:4, Revision Date: 04/28/21) stated, in part::: IV. Procedure: B. Site inspection, connection, and pump rate verification 4. Explain procedure to patient 5. Inspect site through transparent semipermeable dressing a. Do not remove dressing unless IV is rotated, if excessive drainage or moisture is noted, or if integrity of the dressing is compromised b. Transparent semi-permeable dressings should be changed every 7 days c. Gauze dressings should be changed every 48 hours Peripheral Intravenous Catheter Insertion and Dressing Change 6. Inspect and palpate insertion site for infusion related signs and symptoms such as: a. Discoloration (blanching/erythema) b. Disruption of sensation (pain, tenderness, numbness) c. Edema (pitting, nonpitting) d. Localized swelling e. Exudate 1. Consider obtaining an order for cultures 2. Contact licensed independent practitioner (LP) for an order f. Increase in skin and/or basal temperature g. Pain and/or discomfort at the IV site 7. If there is evidence of complication or impending complication, remove the IV and notify LP (licensed practitioner) as indicated.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 31597 Based on record review, interview and policy review, the facility failed to document intravenous (IV) site condition assessments for three (Patients #8, #16 and #17) patients. The facility’s census was 433. Findings include: 1. Patient #17 was interviewed on 05/23/24 at 8:24 AM. Patient #17’s right arm IV site, located in the antecubital fossa (AC), was observed with circular bruising, approximately the size of a golf-ball. Patient #17 was questioned as to if the IV site was causing any pain. Patient #17 reported the right arm IV site was painful and that Patient #17 had reported the pain to a nurse who had flushed the site earlier. Patient #17 reported the site burned for 30 minutes after the nurse flushed the site. Nursing staff discontinued Patient #17’s IV site after the observation. The medical record for Patient #17 contained documentation stating the right arm IV site was discontinued on 05/23/24 at 9:00 AM. The Removal Reason was listed as “Site Change”. The medical record did not contain documentation regarding the patient ‘s reported pain or regarding the bruising at the IV site. The findings were shared with Staff CC on 05/23/24 at 8:24 AM, at the time of the observation, and confirmed. 2. Patient #8 was admitted to the emergency department on 12/02/23 and was discharged on 12/03/24. Patient #8 went to the emergency department for blurred vision for more than one week. She had not had her blood pressure medications in two to three months due to being new to the area and not establishing with a physician. Patient #8 was interviewed on 05/07/24 at 10:19 AM. Patient #8 reported she screamed and cried the night of 12/02/23 to have the staff remove her left arm IV site and they would not listen to her. Patient #8 stated they even had an ultrasound technician come into her room and informed the staff her IV was not in place. On 05/08/24 at 8:37 AM, Staff F reported Patient #8 informed Staff F that the IV site hurt so Staff F verified it with an ultrasound machine, flushed the site with good blood return, and informed Patient #8 that the IV was in place and working properly. Staff F reported that Patient #8 never asked or demanded to have her IV site removed. Staff I was interviewed on 05/08/24 at 9:47 AM. Staff I that Staff F reported to Staff I that Patient #8 was complaining of the IV site hurting and Staff F had assessed it, but Patient #8 was still complaining. Staff I then went to assess the IV site, himself. Staff I stated he flushed the IV site and it flushed easily and had good blood return. Staff I also reported that he used the ultrasound machine to verify the placement and it showed the IV catheter in the vein. Staff I offered a new IV site to Patient #8 and at first, Patient #8 refused but eventually did receive one. Staff I reported Patient #8 was not asking to have the IV site removed she was just complaining it hurt. Staff T was interviewed on 05/28/23 at 3:12 PM. Staff T reported Patient #8 had Patient #8’s IV site placed in the pit (up front) area of the emergency department. “When she came back to my room, she had multiple complaints about it”. Staff T and a paramedic checked it, and it was still working. Staff I looked at it and determined it was patent. Patient #8 “said that it hurt” and was concerned because nobody had ever placed an IV in that location before. The IV was in her upper arm, above the antecubital. Staff T was unable to recall if the IV was in the right or left arm. Staff T reported Staff T flushed the IV and it had no problems. “It was pulling back blood”. Staff T reported the IV site “was hurting” Patient #8. “When I flushed it, she was acting as if she was in agony, she was constantly touching at it”. Staff T reported Patient #8 was always very vocal, she never stopped even when there was nothing going through the IV. “I did not document the issues with the IV, I let my physician know”. Staff T stated Patient #8 never asked Staff T to remove the IV site. Staff T reported Patient #8 “said it hurt, and she was concerned that she never saw an IV placed there before”. “I did not remove the IV. Had she asked me to remove the IV, I would have removed the access”. Staff T stated the facility wouldn’t give up IV access until another IV site was established, unless the site was infiltrated. The medical record for Patient #8 contained documentation by Staff S on 12/03/23 at 3:44 AM stating Patient #8 was complaining of pain of 8 in bilateral arms. The medical record of Patient #8 contained the following IV (intravenous) documentation: 12/02/23 9:21 AM - Upper arm Left - ultrasound peripheral IV start. 18 gauge. Dressing clean, dry and intact. Flushes easily. No complications. Number of attempts = 1. 12/02/23 10:00 AM - Upper arm Left - ultrasound peripheral IV start. 18 gauge. Dressing clean, dry and intact. Flushes easily, 10 ml normal saline flush, good blood return. No complications. PRN (as needed) Adaptor 12/03/23 1:00 AM - Right Antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor. - Upper arm Left - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor. 12/03/23 3:44 AM - Right Antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor. 12/03/23 9:35 AM - Right antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor. 12/03/23 4:37 PM - Right Antecubital - Assessed. Dressing clean, dry and intact. Flushes easily. Site Condition: No complications. PRN Adaptor. The medical record did not contain documentation of Patient #8’s pain at the IV site. 3. On 05/22/24 at 9:18 PM, the medical record of Patient #16 contained documentation stating a peripheral IV in the right hand (inserted on 05/20/24) was discontinued and the site was changed. A new IV site was started on Patient #16 on 05/22/24 at 10:01 PM in the left hand. The medical record did not contain the condition of the site at the time of removal. Per interview with Staff CC on 05/23/24 at 2:47 PM, staff are able to document the following under IV site condition in the electronic medical record: No complication, Blanched, Bleeding, Blistered, Circulatory Impairment, Cool to touch, Crepitus, Drainage present, Ecchymotic, Edema, Erythema, Hematoma, Hot to touch, Infiltrated with non-irritant, Infiltrated with blood, irritant or vesicant, Numbness, Pain, Red streaks, Tight, leaking, Translucent. The facility’s Intravenous (IV) Peripheral Catheter Site Inspection, Care and Rotation policy (4:4, Revision Date: 04/28/21) stated, in part: IV. Procedure: A. An RN (registered nurse) will assess and document the IV site at least every 4 hours B. Site inspection, connection, and pump rate verification 6. Inspect and palpate insertion site for infusion related signs and symptoms such as: a. Discoloration (blanching/erythema) b. Disruption of sensation (pain, tenderness, numbness) c. Edema (pitting, nonpitting) d. Localized swelling e. Exudate 1. Consider obtaining an order for cultures 2. Contact licensed independent practitioner (LP) for an order f. Increase in skin and/or basal temperature g. Pain and/or discomfort at the IV site 7. If there is evidence of complication or impending complication, remove the IV and notify LP (licensed practitioner) as indicated 9. Remove gloves and perform hand hygiene 10. Document site assessment in the medical record including but not limited to: Documentation in the Electronic Medical Record Center Electronic Medical Record (EMR) Downtime Procedure a. Location of the IV b. Angiocath size c. Fluid infusing d. Site appearance F. IV Phlebitis 1. Can occur up to 48 hours post catheter removal 2. Inspect insertion site for signs of tenderness, redness, warmth, edema, pain, inflammation, and/or vein induration 3. Swelling with a feeling of warmth at the site is the best indicator of phlebitis 4. Consider type of solution and/or medication infusing into affected area 5. Remove IV catheter if phlebitis is present 6. If an infection is suspected, obtain an order from the LP for culture prior to removal 7. Notify LP regarding any phlebitis 8. Apply a cold compress to site initially, followed by a warm compress 9. Elevate extremity 10. Document in patient’s medical record 11. A void use of the affected extremity if possible 12. Document patient education as indicated 13. Continue to monitor site until resolution of phlebitis G. IV Removal 1. Verify LP order 2. Perform hand hygiene 3. Verify patient’s identity 4. Don clean gloves 5. Explain procedure to patient 6. Discontinue administration of all infusions prior to catheter removal 7. Remove dressing from catheter insertion site 8. Inspect catheter skin junction site 9. Disinfect catheter junction site with alcohol wipes to reduce risk of infection 10. Place a gauze pad over insertion site 11 . Using gentle, even pressure, slowly retract catheter from the site while holding site with gauze a. If resistance or complications occurs, discontinue removal and notify LP immediately 12. Assess integrity of the removed catheter. Verify that the entire catheter has been removed a. Notify LP if catheter is not intact 13. Apply pressure to the exit site for at least 30 seconds or until hemostasis is achieved 14. Apply a new gauze pad or Band-Aid to exit site 15. Remove gloves 16. Perform hand hygiene 17. Document in the medical record. a. Patient education as indicated b. Catheter removal c. Condition of site H. Rotation of IV site 1. Peripheral intravenous catheters will be rotated when clinically indicated a. Assess site and surrounding area, by palpation and inspection, including catheter pathway, for integrity of skin, dressing, and securement device b. Identify signs of complications, evidence of dislodgement, redness, tenderness, swelling, infiltration, induration, body temperature elevation, drainage or pain.”