HospitalInspections.org

Based on document review and staff interview, it was determined the hospital did not formulate and implement nursing policies and procedures to provide guidance for the care needs of patients who have femoral intravenous catheters.

Findings include:

Review of MR#1, identified that on 12/3/15, the patient underwent surgery service ( transplant surgery ) and a had insertion of a Right femoral venous access catheter; the catheter was sutured with three (3)-0 silk sutures, and a biopatch and sterile gauze dressing were applied. It was noted that the catheter size was not recorded. Hemodialysis was performed through the femoral access, commencing at 9:45 PM and terminating at 11:45 PM.

Review of the hemodialysis flow sheet for 12/4/15 found that the patient had hemodialysis on 12/4/15 at 10:45 PM and dialysis terminated on 12/5/15 at 12:50 AM; the catheter port "was" cleaned with Chloroprep and (catheter) to stay in."

On 12/7/15 at 0150 (1:50 AM), the catheter was found to be dislodged with only one (1) suture in place.

At interview with the nursing aide on 1/21/16 at approximately 2:00 PM, it was stated that when she attempted to take the patient's vital signs, she saw blood on the sheets and found that the femoral catheter was dislodged and there was one (1) suture held in place.


Review of nursing policies and procedures titled, " Initiation and Termination of Hemodialysis Using a Femoral Catheter," original issue date 1/2008 and effective 3/2013, found that the policy addressed the insertion of the catheter, care of the patient in the intradialytic phase (during hemodialysis) and post dialysis care. The policy, however, did not address nursing responsibility where the patient will have the femoral catheter remaining in place for multiple dialysis treatments.
Review of the facility policy authored by the Infection Control Committee, titled "Prevention of Intravenous Therapy - Related Infection," original issue date 1984 (no month ), addressed infection prevention activities, not activities to prevent catheter related malfunctions.


There was no facility policy and procedure to provide guidance for the nurse in the care needs and assessment of patients who have femoral intravenous catheters and to ensure that the catheter/sutures remain in place.

There was no evidence of a nursing care plan to address the need for nursing staff to modify care rendered to a patient who has a femoral dialysis catheter (not tunneled) in place and is at risk for dislodging and subsequent hemorrhage.