HospitalInspections.org

Based on record review and interview the facility failed to ensure patients receive care in a safe setting consistent with sound nursing practice in 1 of 10 medical records reviewed (Pt. (patient) #1) and failed to follow policy in the reporting of an abnormal finding on x-ray in 1 of 10 medical records reviewed (Pt. #6).

Findings:

Patient discharged with intact IV catheter

Review of facility policy titled, "Patient Rights and Responsibilities, AW (Ascension Wisconsin)" dated 3/14/2020 revealed, "Procedure: ...#11. Receive compassionate, personal care, consistent with sound medical and nursing practice in a clean, safe and secure environment..."

Review of Pt. #1's medical record revealed he was discharged at approximately 12:25 PM on 1/23/2024. The medical record revealed a nurses note that was dated 1/23/204 at 2:43 PM, "Shift Summary: ...Patient pulled out IV and walked down hallway towards elevator because he wanted to wait for niece to pick him up downstairs in the main lobby and not his room." The record revealed that the patient became unresponsive in the lobby at approximately 1:05 PM and resuscitation efforts were unsuccessful.

Review of the facility policy titled "Intravenous (IV) Therapy- Invasive Lines, AW (Ascension Wisconsin)" dated 12/21/2023 revealed no policy statements regarding removal of intravenous catheters at discharge.

On 2/13/2024 at 9:40 AM in the interview with CVICU (Cardiovascular Intensive Care Unit) Manager F, Manager F stated, "As far as the IV, he (Pt. #1) told the nurse that he had taken the IV out and (RN P) believed him. Of course, we routinely remove IV catheters at discharge." The RN believed that he had discontinued his own IV however did not verify. The patient was discharged from the ICU (intensive care unit) with an intact capped IV catheter in place.


Unreported abnormal finding on x-ray

Review of facility policy titled, "Critical results Reporting for Medical Imaging" dated 10/21/2021 revealed, "Policy: Critical results and critical tests results will be reported by the Radiologist to a licensed caregiver authorized to make clinical decisions or his/her designee within one (1) hour of findings. Critical results would be defined as any study with an abnormal finding in which the clinician needs to make a decision in the care of the patient within 24 hours (i.e. prior to receiving the typed dictated report)."

Review of Pt. #6's medical record revealed a portable chest x-ray was ordered by the ICU Intensivist Physician Assistant on 12/13/2023 for hypoventilation (breathing that is too shallow or too slow) likely due to splinting from post-op pain citing needs a CXR (chest x-ray) has not had one postoperatively yet."

The medical record revealed that the CXR was ordered at 2:00 PM and completed and read at 4:44 PM. The report "X-ray Chest Portable: Patient Communication" in the medical record revealed, under Impression, "1. There is a radiopaque ribbon over the RIGHT upper quadrant abdomen. Its exact location is otherwise indeterminate on the basis of this study. It may be overlying or post surgical but will need CLINICAL CORRELATION TO EXCLUDE A RETAINED FOREIGN BODY SUCH AS A SPONGE..."

The x-ray was read with a finding of a potential retained foreign body with a note indicating that clinical correlation was necessary to confirm the findings. No notification to the provider of the potential critical finding was made by the Radiologist.