Inova Specialty Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 36946 Based on observations, staff (EMP) interview, document review, and review of medical records (MR), it was determined the hospital failed to ensure all nurses adhered to the policies and procedures of the hospital. Specifically, nursing staff failed to follow established policies and procedures related to the care and maintenance of both centrally and peripherally inserted intravenous (IV) catheters in eight (8) of nine (9) records reviewed in the survey sample. MR1, MR3, MR4, MR5, MR6, MR9, MR10, and MR11. Findings: The facility’s policy, “Intravenous Therapy: Short Peripheral and Midline IV Therapy,” last revised July 01, 2024, was reviewed and reads in part, “...General Policy Statements...10. Dressing changes - whenever the dressing becomes damp, loosened or visibly soiled. TSM (transparent semipermeable membrane) dressing every 7 days.... 1. MR1 contained documentation that the patient was admitted from an outside hospital on January 28, 2026, with a peripheral IV line in the left posterior forearm placed on an unknown date. The first assessment of the IV site was not completed by a nurse until January 30, 2026. The documentation contained no information related to when the dressing was last changed by the previous hospital. The nurse documented on the assessment flow sheet on January 30, 2026, that the TSM dressing was due to be changed on January 30, 2026. Review of the medical record indicated the dressing was not changed until February 01, 2026. 2. MR3 contained documentation that the patient was admitted on January 16, 2026. MR3 arrived with a midline in the right upper arm placed at an outside hospital on January 03, 2026. The medical record contained no documentation on admission of when the IV dressing was last changed. The medical record was reviewed on February 04, 2026, and contained no documentation that the dressing had ever been changed by the facility in the 19 days since the patient was admitted. After reviewing the record, the surveyor conducted observations of MR3’s IV site at 2:29 PM on February 04, 2026. The surveyor observed the date on the midline dressing was documented as February 04, 2026. The patient’s nurse (EMP5) was interviewed at 2:33 PM on February 04, 2026. EMP5 indicated that they had changed the dressing to the patient’s midline earlier in the day. EMP5 indicated that prior to changing the dressing they reviewed the medical record and could not determine the last date of the dressing change or when the dressing was due to be changed. EMP5 assessed the dressing and IV site and indicated the dressing looked like it should be changed. 3. MR5 contained documentation that the patient was admitted on November 12, 2025, with a peripheral IV to the right upper arm inserted by an outside hospital on an unknown date. The first dressing change to the IV was documented as November 26, 2025, two (2) weeks after the patient’s admission. The patient had a second peripheral IV inserted on November 29, 2025, and covered with a TSM dressing. The dressing should have been changed by December 6, 2025, according to facility policy. There was no documentation that the IV dressing was ever changed from the time of insertion on November 29, 2025, to the time of discharge on December 15, 2025 (a sixteen (16) day period). 4. MR6 contained documentation that the patient was admitted November 24, 2025, with a midline in the right upper arm inserted in an outside hospital. The record contained no documentation on admission of when the midline TSM dressing was last changed. The first documented midline dressing change in the record was December 20, 2025 (twenty-six days after admission). The dressing was changed again on December 24, 2025. The medical record contained no documentation that the dressing was changed after December 24, 2025. The patient was discharged on January 7, 2026, (2) weeks after the last dressing change. The facility’s policy, “Central Venous Access Devices (CVAD”) last revised January 01, 2026, was reviewed and reads in part, “...Flushing and locking...CVADs are flushed using single use flush after each infusion to clear the infused medication, thereby reducing the risk of contact between incompatible medications. The CVAD is locked after completion of the final flush to decrease the risk of intraluminal occlusion and catheter-related bloodstream infection...Documentation: flush lock solution and volume, date, time of administration, route specific CVAD or lumen used for administration...” “...Assessment, Site Care/Dressing Changes...CVAD catheter site care and dressing changes are performed at established intervals and immediately when the integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment of site infection or inflammation is suspected. In general, change dressing as follows: On admission...TSM every 7 days...” The hospital’s “Central Line Dressing Change Competency” was reviewed and indicated that after changing the central line dressing the nurse...”performs post-dressing change care and tasks. Places label on dressing with date, time, and initials. Documents appropriately in the medical record...” 5. MR4 was admitted on January 29, 2026, with a double lumen PICC (peripherally inserted central catheter, a type of CVAD) in the left arm that was placed by an outside hospital on December 12, 2025. The medical record contained no documentation that the PICC line dressing change was completed on admission as required by hospital policy. The record contained no documentation of when the dressing was last changed. The first documented dressing change was February 03, 2026. The nursing assessment on February 03, 2026, indicated that the PICC line was “flushed.” The record failed to contain any documentation of the flush solution and volume and the lumen that was flushed. 6. MR 9 was admitted January 15, 2026. The patient had a double lumen PICC line placed to the left upper arm on January 28, 2026. At the time of record review on February 5, 2026, at 10:50 AM, there was no documentation the PICC line dressing had been changed, but should have been changed by February 4, 2026, according to facility policy. The Registered Nurse (RN) documented that the PICC line was flushed at 8:00 AM on January 29, 2026, but failed to document the solution and volume of the flush and what lumen(s) were flushed. 7. MR10 was admitted February 2, 2026, with a single lumen PICC line in right arm placed by an outside hospital. The record contained no documentation that the PICC dressing was changed at the time of the patient’s admission. The RN documented on February 3, 2026 at 8:00 PM, February 4 2026, at 8:00 PM, and February 5, 2026 at 8:00 AM that the PICC line was “flushed.” The medical record failed to contain documentation of what solution, the volume, and what lumen(s) were used for each of these flushes. 8. MR11 had a PICC line placed in the facility on January 21, 2026. After insertion, the medical record contained no further documentation of the PICC line site to include justification for central line, site assessment, dressing type and integrity for six days. An interview was conducted with EMP2 at 11:00 AM on February 4, 2026. EMP4 indicated that the RN should assess the IV site each shift and document findings. The PICC line dressing was changed on January 27, 2026. The next documented dressing change was nine (9) days later February 5, 2026. An interview was conducted with EMP4 on February 04, 2026, at 3:30 PM. EMP4 indicated that they were made aware that MR6’s midline dressing had not been changed in a prolonged time after the patient’s family contacted hospital leadership on December 20, 2025. EMP4 indicated they changed the midline dressing later that day. EMP4 indicated that there had been some confusion related to line dressing changes as the facility has a “line nurse” that changes all central line dressings. Additionally, only house supervisors and the line nurse are permitted to change PICC line dressings. Midline dressings, however, are changed by the bedside nurse. Some staff members erroneously thought the line nurse or the house supervisors were responsible for changing midline dressings. EMP4 further indicated that all central line dressings to include PICC lines, should be changed upon admission. Peripheral IV dressings to include midline dressings are not changed on admission but should also be changed at least every 7 days. EMP4 indicated there was no way to confirm when the dressing was changed/placed if the peripheral IV was placed in another facility, and therefore impossible to know when the first dressing change should occur. EMP4 indicated that when a dressing is changed, it should be initialed and dated 7 days in the future in order for other staff to know when the dressing is due to be changed. EMP4 indicated they did not know if other nurses followed that practice or if they labeled the dressing with the date it was actually changed. The competency document provided to the survey indicated the dressing should be labeled with the date it was changed, not a future date. An interview was conducted with EMP2 on February 05, 2026, at 9:45 AM. EMP2 indicated that staff should be documenting the flush solution, volume, and lumen flushed when assessing the patency of a central line. EMP2 indicated this information was currently being infrequently documented in the medical records reviewed.”