HospitalInspections.org

Based on record review and staff interviews, it has been determined that the hospital failed to meet the Patient Right's Condition of Participation in failing to ensure care in safe setting for 2 sampled patients.

Findings are as follows:

1. The hospital failed to provide care in a safe setting related to Central Venous Line Insertion in failing to remove a metal guide wire from Patient ID #1.

2. The hospital failed to provide care in a safe setting related to performing a wrong site incision while attempting to remove K-wires from Patient ID #2's hand.

(refer to A 144)



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Based on record review and staff interviews, it has been determined that the hospital failed to ensure that patients received care in a safe setting related to the failure to remove a guidewire following a central venous catheter insertion for Patient ID #1 and relative to the failure to follow policy prior to initiating surgical removal of K-wires for Patient ID #2.

Findings are as follows:

1. Record review revealed Patient ID #1 presented to the hospital's emergency department (ED) on 7/18/2019 for generalized weakness. The patient was found to have severe low blood pressure and renal failure. Patient ID #1 was admitted to the intensive care unit (ICU) and required a right internal jugular (IJ) central venous catheter placement on 7/18/2019.

The record indicates Patient ID #1's condition had improved, and s/he was discharged from the hospital on 7/24/2019.

Further record review revealed that the patient felt well after discharge however, on 7/30/2019, s/he experienced generalized weakness, whole body pain, and feeling very cold. Patient ID #1 saw her/his primary care physician on 7/31/2019 and was sent for a chest X-ray.

Record review revealed that on 8/2/2019, the patient's primary care physician (PCP) called and advised Patient ID #1 to go to the ED after review of her/his chest X-ray. The X-ray showed that Patient ID #1 had a guidewire within her/his right neck, extending into the chest. The patient reported to the PCP that s/he had a central venous catheter placed in the right neck while while admitted at the hospital between 7/18/2019-7/24/2019. The PCP told the patient to return to the hospital to have the guidewire removed.

Review of an 8/3/2019 Radiology Procedure Note revealed the patient received conscious sedation and had fluoroscopic images performed. The fluoroscopic images indicate Patient ID #1 had a retained guidewire within the right Jugular vein extending to the level of the hepatic vein (carries blood from liver to the heart) and looped within the heart. The retained guidewire was removed through the right internal femoral vein (deep vein of the thigh).

During an interview on 8/8/2019 at 9:45 AM with the physician (Staff A), who performed the central venous catheter placement on 7/18/2019 for Patient ID #1, she revealed that she had performed the procedure independently. She stated she did not recall if she removed the guide wire or not. She stated the post procedure X-ray verified the catheter tip placement.

Record review revealed a chest X-ray on 7/18/2019 at 9:29 PM, with findings recorded as "Lines/tubes: Interval placement of right Internal jugular line with tip at the cavo-atrial junction..."

During an interview with the radiologist (Staff C) on 8/8/2019 at 11:30 AM, he revealed that on 7/18/2019 he did not identify the retained guidewire as he was reviewing the film for the catheter placement.

During an interview with the Risk Manager on 8/9/2019 at approximately 10:00 AM, she was unable to provide evidence that the guidewire was removed during the placement of Patient ID# 1's central venous catheter on 7/18/2019.


2. The Hospital's policy entitled, "Universal Protocol for Procedures Performed Outside of the Operating Room; Verification of Patient Identity, procedure and Site/Side" states in part;

" II. Policy included procedures ...
c. This policy applies to invasive procedures involving puncture/incision of the skin or insertion of an instrument or foreign material into the body ...

Definitions
Proceduralist: a licensed professional who is credentialed by the hospital to perform the procedure is responsible for ensuring UP (Universal Protocol) is performed and documented.
Verifier: The nurse, technologist or assistant working with the patient is responsible for verifying with the proceduralist the correct patient, procedure, and, when applicable, the marking of the site/side of the intended procedure.

III Procedure: Verification, Site Marking, Briefing, Time Out, and Debriefing
Step 1: Verification

1. The proceduralist must participate with the Verifier along with the patient or the patient representative, to confirm the patient's identity and the intended procedure, including site and side as it appears on the primary source documents ...
3. The dated, timed and signed consent form must include the patient's full name, date of birth and a description of the procedure including the site and if applicable the side ....

Step 2. Site Marking is performed
Documentation of step 2 site marking is completed in the EHR (electronic health record) or on paper form ...

Step 4 Time Out is performed."

Review of Patient ID #2's clinical record, revealed that s/he was brought to the ED on 6/22/2019 , for psychiatric evaluation, after being found walking in the middle of the street, A "Provider Note" states that the patient presented to the ED with suicidal ideation and complaints of right index finger pain since having surgery approximately 2 months ago.

Additional record review revealed that during a previous admission on 4/8/2019 the patient had a fracture and underwent a closed reduction for the right index finger with the insertion of K-wires (surgical pins)to stabilize the fracture. Review of the patient's discharge record from the hospital on 4/10/2019 confirmed that s/he had a follow up appointment with the plastic surgeon scheduled for 4/18/2019 at 8:15 AM but had not attended.

Review of a "significant event note," dated 6/22/2019, revealed that physician (Staff B), in attempting to remove a superficial K-wire, performed a surgical incision on the patient's wrong hand. The note further indicates that Staff B was called to the ED for follow-up removal of K-wires and the decision was made to remove the K- wires at the bedside in the ED. Staff B confirmed (erroneously), with the patient, that the K-wires were in the left index finger, a local block was performed with lidocaine and an incision was made on the left index finger.

During surveyor interview with the physician, (Staff B) on 8/7/2019 at 2:50 PM, he revealed that he was called to the ED on 6/22/2019 regarding pain in the patient's right hand. Staff B indicated that the patient had not followed up to have the K-wires removed after surgery. Further, that after reviewing the X-ray taken of the right hand on 6/22/2019 he decided to remove the K-wires at the bedside. He stated that he spoke with the patient and that the patient confirmed it was her/his left hand. He thought he felt the pins on the left index finger, proceeded to inject the lidocaine block and make an incision to remove the K-wires. When he found no K-wires in the left finger, he realized that he had performed the incision on the wrong side. Staff B acknowledged that prior to performing the incision, he had not; obtained a signed consent including the site of the procedure, participated with a nurse, technologist or assistant to verify the marking of the site/side nor participated in a time out, per policy.