HospitalInspections.org

Based on observation, medical record review, review of policy and procedure, review of staff orientation and staff interviews, the Critical Access Hospital (CAH) failed to administer intravenous (IV) medications according to facility policy and procedure for 1 of 1 medical record (Patient 1) reviewed, and failed to document IV assessments according to facility policy and procedure for 3 of 3 medical records (Patient 1, 34 and 36) reviewed. This failed practice had the potential to affect all inpatients. The CAH reported 886 inpatients for fiscal year 2022.

Findings are:

A. Medication administration observation (5/15/2023 at 3:25 PM) of Registered Nurse (RN)-A for Patient 1 revealed the RN-A preparing IV Vancomycin (an antibiotic) 1 gram, and normal saline 0.9% (mixture of sodium chloride and water) 50 ml (milliliter) with new IV tubing on medication room countertop without disinfecting the surface. Observation also revealed that RN-A while priming (placing IV fluid in IV tubing to remove all air prior to attaching the IV tube to the patient) left multiple large visible air spaces in the IV tubing that attached to Patient 1's peripherally inserted central catheter (PICC) line. RN-A observed not to flush the PICC line with 10 ml normal saline syringe, assess, or check for patency (a way to check the IV line for blood return to verify the line is functioning properly) prior to attaching the IV tubing to Patient 1. The IV pump alarmed with an error message that read "distal occlusion" (an alert that detects blockages or air in the IV tubing). RN-A stated, "these IV machines are always picky". RN-A observed to open the IV machine and flick the air spaces out of the IV line while attached to the patient. RN-A observed pressing a button on the IV machine to remove the remaining air spaces from the IV tubing. Patient's right arm observed bent at the antecubital (crook of the elbow) where the PICC insertion site was located, site not visible, and RN-A did not have the patient move their right arm before, during, or after the IV medication started.

-Review of policy and procedure titled Central lines/Central Access Device Care and Maintenance (Revised June 2021) revealed the following under Vascular Device Flushing:
"1. To provide safe and effective line flushing for all type of intravenous catheters in order to maintain catheter patency.
2. All vascular access ports will be flushed following aseptic (prevent infection) technique using the appropriate solution, volume, frequency, syringe size and technique to maintain patency.
3. Flush the line a minimum of once per shift if not being used...
9. This minimizes fibrin collection and clot formation. Using a forward pushing motion on the syringe with a push-pause technique applies turbulence to an intravenous device. This promotes a swirling and vigorous fluid movement that can remove blood cells, fibrin, or protein build-up on the walls of the intravenous device. To ensure no blood refluxes into the catheter causing an occlusion of the line."

The policy and procedure also included the following PICC line complications: "Fibrin sheath formation (clot surrounding PICC catheter), thrombosis (clot), infection, air embolism (air bubble), pneumothorax (air leaks into the space between the lungs and chest wall causing a collapsed lung), hemothorax (collection of blood between the lungs and chest wall that can cause a collapsed lung), notify the physician for any of the following signs and symptoms: catheter tip in right atrium (chamber in the heart), sudden increase in heart rate, decrease in external catheter length, catheter tip in jugular vein, patient hears bubbling in ear when catheter is flushed, patient has sudden ear ache on side of catheter, catheter malfunction, inability to infuse fluid through catheter at prescribed rate, absence of substantial free-flowing blood return, patient must be re-positioned to obtain blood return, arm swollen on side of catheter, visible collateral chest veins, catheter leaking, stop infusion, fold catheter over on to itself and secure with tape."

-Interview with Chief Nursing Officer (CNO) (5/16/2023 at 9:20 AM) confirmed that RN-A should have flushed the PICC line prior to IV medication administration, acknowledged air spaces due to incorrect prime of IV tube, and no assessment of PICC site prior to IV medication administration.

-Interview with the Infection Control (IC) nurse (5/17/2023 at 9:20 AM) confirmed that RN-A should have disinfected the countertop in the medication room, flushed and checked for blood return prior to IV medication administration. The infection control nurse confirmed IV medication administration and PICC line care assessments are not validated or audited after an RNs' initial orientation.

-Review of RN-A's new hire orientation checklist revealed a hire date of April 27, 2020, and was validated on central line associated bloodstream infection (CLABSI) prevention completed on September 28 (no year), and was validated on IV pumps and demonstrated IV tube set up on September 12 (no year).

-Interview with CNO (5/17/2023 at 12:45 PM) confirmed no further documentation of IV education or training for RN-A beyond the new hire orientation checklist.

B. Review of Patient 1's medical record revealed an admission date of 4/29/2023 for lower leg cellulitis. Review of the entire medical record revealed a lack of nurse documentation of the external length of the PICC line catheter on the following days:
-5/12/2023 PICC line external length not documented,
-5/13/2023 PICC line external length not documented,
-5/14/2023 PICC line external length not documented,
-5/15/2023 PICC line external length not documented,
-5/16/2023 PICC line external length not documented,
-5/17/2023 PICC line external length not documented.

-Review of Patient 34's medical record revealed an admission date of 1/7/2023 for Sepsis (blood infection), Methicillin-Sensitive Staphylococcus aureus (MSSA) bacteremia (type of blood infection), and Pulmonary Embolism (PE) (blood clot in the lungs). Review of the the entire medical record revealed a lack of nurse documentation of the external length of the PICC line catheter on the following days:
-1/15/2023 PICC line catheter external length not documented,
-1/17/2023 PICC line catheter external length not documented,
-1/18/2023 PICC line catheter external length not documented,
-1/19/2023 PICC line catheter external length not documented,
-1/20/2023 PICC line catheter external length not documented.

-Review of Patient 36's medical record revealed an admission date of 5/09/2023 for a Septic knee joint (infection in the knee joint) and Endocarditis (infection in the heart). Review of the entire medical record revealed a lack of nurse documentation of the external length of the PICC line catheter on the following days:
-5/12/2023 PICC line catheter external length not documented,
-5/16/2023 PICC line catheter external length not documented.

-Review of policy and procedure titled Central lines/Central Access Device Care and Maintenance (Revised June 2021) revealed the following under Peripherally Inserted Central Venous Catheters (PICC) "Measure the external catheter length daily."

-Interview with the CNO (5/17/23 at 3:15 PM) confirmed the PICC line external length was not documented in the above medical records per policy and procedure.