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Based on review of medical records, hospital policies, and staff interviews, the facility failed to obtain proper informed consent from a legally designated representative, as required when a patient is incapacitated or otherwise unable to communicate. Hospitals must seek the consent of the legal representative whenever consent is required for care. This deficiency was identified in 1 (Patient #2) of 3 patients sampled.

Findings include:

1) From December 29, 2024, through January 12, 2025, the patient was readmitted with acute changes in mental status that ultimately led to a fatal outcome. She arrived via EMS on December 29 at 16:45, unresponsive, and was triaged at 16:51 with an ESI acuity level of 3 (Urgent). An 80-year-old female with ESRD on a Tuesday/Thursday/Saturday dialysis schedule, she had decreased mentation of unknown onset, and family, noted increased fatigue and poor oral intake over the past two days. A CT scan of her head showed no acute intracranial abnormality, though mild atrophy was present. The emergency physician started empiric antibiotics-despite no overt hypotension or lactic acidosis-and consulted both Nephrology and Cardiology, given concern for a high troponin (20.94) and a possible cardiac etiology. The patient's mental status improved slightly but remained below baseline. By 9:30 PM, she was transferred to the Intensive Care Unit (ICU).
The facility discovered the Quinton central line was still in place from the prior admission approximately six weeks prior. In the ICU, her labs revealed a hemoglobin of 7.4 g/dL and platelets of 43 × 10^3/?L. She deteriorated further, developing hypotension consistent with septic shock. Blood cultures returned positive for coagulase-negative Staphylococcus and Proteus, and catheter-tip culture also confirmed those organisms, implicating the central line as the likely source of infection. The old catheter was removed and replaced, and she was treated with broad-spectrum antibiotics (vancomycin and cefepime). Despite these measures, she worsened, with CT evidence suggestive of new bilateral occipital infarcts. She required vasopressors, developed persistent thrombocytopenia and anemia necessitating multiple transfusions, and tested positive for Clostridium difficile again, receiving oral vancomycin.
By January 12, 2025, the patient's prognosis was extremely poor. The family was informed of her grave condition and chose to proceed with comfort measures. Nurse notes indicate that at 14:35, the daughter requested a compassionate extubation; by 14:57, she was extubated to room air with family present. She subsequently became apneic, was pronounced asystole at 15:42, and was officially declared deceased. Her final diagnoses included septic shock secondary to a central line-associated bloodstream infection, multifactorial encephalopathy, acute respiratory failure, ESRD, thrombocytopenia, multifactorial anemia, Type II Diabetes Mellitus, C. diff colitis, and heart failure with preserved ejection fraction. This clinical course and ultimate outcome were traced largely to the infected Quinton catheter that had been left in place.

On February 19, 2025, at approximately 1:00 PM, an interview was conducted with the Accreditation and Regulatory Quality Manager, who confirmed that no informed consent had been obtained. She explained the facility proceeded under the assumption of implied consent because the patient was incapacitated upon arrival to the Emergency Department.

On February 24, 2025, an email from the same Accreditation and Regulatory Quality Manager confirmed there was no signed informed consent by the patient's daughter at any point during the admission. She indicated this deficiency was recognized as an opportunity for improvement.

A review of the facility policy titled "Informed Consent," last approved July 2024, revealed that on page 3 under "Incapacitated Adult Patients," the policy specifies the facility will seek direction from various forms of legal representatives when patients are unable to consent on their own.

Based on record review, policy review, and staff interviews, the facility failed to provide care in a safe setting by leaving a temporary Quinton catheter in place at discharge, resulting in a readmission due to sepsis, and died for 1 (Patient #2) out of 3 patients sampled.

The Findings include:

1) From November 8 through November 14, 2024, the patient, an 80-year-old female with End-Stage Renal Disease (ESRD) on a Tuesday/Thursday/Saturday hemodialysis schedule, was admitted following complications with her arteriovenous (AV) fistula. She arrived by ambulance from a skilled nursing facility with a nonfunctioning fistula that prevented her scheduled dialysis session on a Thursday. A duplex ultrasound of her upper extremity confirmed an occluded brachial vein fistula graft. Despite this, she remained hemodynamically stable, and laboratory values were acceptable, so there was no immediate indication for emergent dialysis.
On November 11, 2024, at 4:05 PM, a temporary (non-tunneled) hemodialysis catheter was placed in her right internal jugular vein due to the occlusion of her AV fistula. Subsequently, on November 13, 2024, at 1:10 PM, Interventional Radiology performed a successful fistulagram and angioplasty that restored her fistula's function, allowing the resumption of hemodialysis through the repaired site. At discharge on November 14, 2024, at approximately 5:22 PM, nursing documentation indicated that the patient was sent via ground ambulance to an Assisted Living or Intermediate Care Facility. The notes specifically mentioned that all lines and tubes were intact, including a Quinton catheter that remained in her right neck. This temporary dialysis catheter was not removed prior to discharge. Failure to remove the catheter resulted in the patient becoming septic and readmitted approximately 5-6 weeks later and ultimately death.

On 2/19/25 at approximately 11:00 AM an interview with the Manager of Risk Management was conducted. She confirmed the successful fistualgram should have triggered the removal of the temporary dialysis catheter. It was also confirmed the temporary dialysis catheter was not removed prior to discharge.

A review of the facility policy titled "Central Venous Access Device & Management" with a last approved date of 06/2024, revealed on page 25, Registered Nurses are allowed to remove non-tunneled catheters.

Based on record review, policy review, staff interviews, the facility failed to ensure an adequate number of licensed registered nurses were available to meet the needs of patients based on acuity (number of patients, severity of illness, training/experience of nurses, and readily available resources that are not assigned other duties), resulting in a non-tunneled central line dialysis catheter not being discontinued at discharge that resulted in sepsis and subsequent death for 1 (Patient #2) of 3 patients sampled.

Findings include:

1) From November 8 through November 14, 2024, the patient, an 80-year-old female with End-Stage Renal Disease (ESRD) on a Tuesday/Thursday/Saturday hemodialysis schedule, was admitted following complications with her arteriovenous (AV) fistula. She arrived by ambulance from a skilled nursing facility with a nonfunctioning fistula that prevented her scheduled dialysis session on Thursday. A duplex ultrasound of her upper extremity confirmed an occluded brachial vein fistula graft. Despite this, she remained hemodynamically stable, and laboratory values were acceptable, so there was no immediate indication for emergent dialysis.
On November 11, 2024, at 4:05 PM, a temporary (non-tunneled) hemodialysis catheter was placed in her right internal jugular vein due to the occlusion of her AV fistula. Subsequently, on November 13, 2024, at 1:10 PM, Interventional Radiology performed a successful fistulagram and angioplasty that restored her fistula's function, allowing the resumption of hemodialysis through the repaired site. At discharge on November 14, 2024, at approximately 5:22 PM, nursing documentation indicated that the patient was sent via ground ambulance to an Assisted Living or Intermediate Care Facility. The notes specifically mentioned that all lines and tubes were intact, including a Quinton catheter that remained in her right neck. This temporary dialysis catheter was not removed prior to discharge.
From December 29, 2024, through January 12, 2025, the patient was readmitted with acute changes in mental status that ultimately led to a fatal outcome. She arrived via EMS on December 29 at 16:45, unresponsive, and was triaged at 4:51 PM with an ESI acuity level of 3 (Urgent). An 80-year-old female with ESRD on a Tuesday/Thursday/Saturday dialysis schedule, she had decreased mentation of unknown onset, and family noted increased fatigue and poor oral intake over the past two days. A CT scan of her head showed no acute intracranial abnormality, though mild atrophy was present. The emergency physician started empiric antibiotics-despite no overt hypotension or lactic acidosis-and consulted both Nephrology and Cardiology, given concern for a high troponin (20.94) and a possible cardiac etiology. The patient's mental status improved slightly but remained below baseline. By 9:30 PM, she was transferred to the ICU for closer monitoring.
While in the ICU, her labs revealed a hemoglobin of 7.4 g/dL and platelets of 43 × 10^3/?L. She deteriorated further, developing hypotension consistent with septic shock. It became apparent that her old temporary Quinton catheter, placed approximately five or six weeks prior, remained. Blood cultures returned positive for coagulase-negative Staphylococcus and Proteus, and catheter-tip culture also confirmed those organisms, implicating the line as the likely source of infection. The old catheter was removed and replaced, and she was treated with broad-spectrum antibiotics (vancomycin and cefepime). Despite these measures, she worsened, with CT evidence suggestive of new bilateral occipital infarcts. She required vasopressors, developed persistent thrombocytopenia and anemia necessitating transfusions.
By January 12, 2025, the patient's prognosis was extremely poor. The family was informed of her grave condition and chose to proceed with comfort measures. Nurse notes indicate that at 14:35, the daughter requested a compassionate extubation; by 2:57 PM, she was extubated to room air with family present. She subsequently became apneic, was pronounced asystole at 3:42 PM, and was officially declared deceased. Her final diagnoses included septic shock secondary to a central line-associated bloodstream infection, multifactorial encephalopathy, acute respiratory failure, ESRD, thrombocytopenia, multifactorial anemia, Type II Diabetes Mellitus, C. diff colitis, and heart failure with preserved ejection fraction. This clinical course and ultimate outcome were traced largely to the infected Quinton catheter that had been left in place.

On February 21, 2025, at 4:27 PM, an email from the Accreditation and Regulatory Quality Manager included acuity documentation from the day Patient #2 was discharged without catheter removal. The facility used the American Nurses Association (ANA) Acuity tool to assign scores. On November 14, 2024, 4 East had 18 patients, mostly telemetry, with a total acuity of 42 points, including Patient #2 at level 3 on a 1-to-4 scale. CMS regulations require staffing to patient complexity rather than a fixed ratio, ANA reccommends it. Based on the total acuity of 42 across 18 patients (about 3.5 care hours per patient per 12-hour shift), the unit needed approximately six nurses. However, only three nurses were scheduled, creating insufficient staffing to meet higher acuity needs.

On February 20, 2025, at 10:45 AM, Employee B (Registered Nurse) was interviewed. She confirmed working the day in question, describing it as "very busy." She admitted difficulty completing patient-care tasks and was unsure if central lines were covered during her orientation. She felt uncomfortable with central lines due to limited exposure and minimal experience, stating the need for more detailed training on various central lines.

On February 20, 2025 at 8:00 PM, a phone interview was conducted with Employee A, who served as Patient #2's primary nurse. She did not remove the central line prior to discharge. Although she was not a new nurse, she was new to the facility and on her final orientation day. Her preceptor was managing other responsibilities and unavailable to assist. Employee A reported no central line training during orientation, no 90-day skills competency follow-up from leadership or education staff, and no one verifying that she was signed off on central line management before being assigned a patient with one in place.

On February 24, 2025, at 6:00 PM, a phone interview was conducted with the Vice President of Nursing, who confirmed that patients are placed in a level of care ordered by the admitting physician, rather than via a shift-by-shift acuity assessment. She indicated that while "resources" existed, those individuals had existing assignments and were not readily available. Therefore, they could not effectively augment coverage for higher-acuity patients.

A review of the facility's policy titled "Staffing/Scheduling - Hospital Campus Locations," last approved in February 2024, referenced "acuity" on page 6, indicating that schedule patterns should be planned to minimize daily staffing adjustments by prescheduling personnel in anticipation of acuity and census variations each day of the week.

Based on policy review, record review, and staff interviews, the facility failed to ensure assigned staff had the proper education and competency to provide proficient care to a patient with a temporary non-tunneled dialysis catheter that contributing to a retained temporary non-tunneled dialysis Quinton catheter at discharge for 1 (Patient #2) of 3 patients sampled.

Findings include:

1)From November 8 through November 14, 2024, the patient, an 80-year-old female with End-Stage Renal Disease (ESRD) on a Tuesday/Thursday/Saturday hemodialysis schedule, was admitted following complications with her arteriovenous (AV) fistula. She arrived by ambulance from a skilled nursing facility with a nonfunctioning fistula that prevented her scheduled dialysis session on a Thursday. A duplex ultrasound of her upper extremity confirmed an occluded brachial vein fistula graft. Despite this, she remained hemodynamically stable, and laboratory values were acceptable, so there was no immediate indication for emergent dialysis.
On November 11, 2024, at 4:05 PM, a temporary (non-tunneled) hemodialysis catheter was placed in her right internal jugular vein due to the occlusion of her AV fistula. Subsequently, on November 13, 2024, at 1:10 PM, Interventional Radiology performed a successful fistulagram and angioplasty that restored her fistula's function, allowing the resumption of hemodialysis through the repaired site. At discharge on November 14, 2024, at approximately 5:22 PM, nursing documentation indicated that the patient was sent via ground ambulance to an Assisted Living or Intermediate Care Facility. The notes specifically mentioned that all lines and tubes were intact, including a Quinton catheter that remained in her right neck. This temporary dialysis catheter was not removed prior to discharge.

2) A review of personnel education files revealed that 5 out of 10 sampled staff members had not received the required central line training. Among those 5 was Registered Nurse (RN) A, who served as the primary RN for Patient #2 and failed to remove the centralline prior to discharge.

On February 20, 2025, at 10:45 AM, an interview was conducted with Employee B, Registered Nurse. She stated that she worked on the floor the day of the incident and described it as "very busy." She was helping other nurses and could not finish her own patient?care tasks. She did not recall whether central lines were included in her orientation. She felt uncomfortable with central lines due to limited exposure and minimal nursing experience, indicating a need for more comprehensive training on various central lines.

On February 20, 2025, at 2:00 PM, Employee C, Nurse Educator, was interviewed. She stated that she and one other educator were responsible for all educational initiatives across six facilities in three different counties, including one under construction. She estimated she could spend only one to two hours per month, per facility, which she admitted was insufficient to fulfill all educational requirements. She noted that unit leadership was expected to follow up on any post?orientation education needs.

On February 20, 2025, at 2:20 PM, an interview was conducted with Employee D, Nurse Educator. She confirmed that she and another educator oversaw new?graduate nurse training for six facilities. The new?graduate program spanned six months, featuring four eight?hour days of hands?on instruction with her. She mentioned that the national Clinical Practice Development (CPD) team had visited all Ascension healthcare facilities in the past to evaluate training, though she could not recall if any changes were made because of those visits.

On February 20, 2025, at 3:30 PM, the Market Clinical Professional Manager was interviewed. She acknowledged missing education components for central lines and incomplete 90?day competency books. She stated that Ascension National recognized a system?wide education gap back in October 2024. She could not produce any documentation indicating actions taken to ensure staff were sufficiently trained after that discovery.

On February 20, 2025, at 3:50 PM, the Market Clinical Professional Director confirmed awareness of the educational gap, noting she reported completion percentages monthly at national meetings. However, she could not provide documentation reflecting these reported percentages or any steps taken to resolve the issue since October 2024.

On February 20, 2025, at 6:30 PM, the Vice President of Nursing confirmed knowledge of the education gaps across Ascension National, explaining she was notified via email in October 2024, along with the Market Clinical Professional Manager and Director. She could not produce documentation suggesting the facility had taken any action in response to this information.

On February 20, 2025, at 6:45 PM, a group interview with Risk Management, Quality, Education, the Director of Nursing, and the Vice President of Nursing took place. The Risk Management Director, the Quality Director, and the Director of Nursing each denied having prior knowledge of the identified gap, stating this group meeting was the first time they had been informed.

On February 20, 2025, at 8:00 PM, a phone interview was conducted with Employee A, the primary nurse for Patient #2. She confirmed that she did not remove the central line before discharge. Although she was not a new nurse, she was new to the facility and on her final day of orientation with a preceptor. Due to high acuity and the preceptor's own patient load, she received minimal oversight. She denied receiving any central line training during orientation or having a 90?day skills competency follow?up by education or leadership. She also stated no one-charge nurse or preceptor-verified she had been signed off on central lines before assigning her to a patient who had one in place.

Education specific policy was unavailable for review.