HospitalInspections.org

Based on medical record review, staff interviews, and facility document review, the facility staff failed to adhere to the patient's plan of care involving "No BP, IV or Venipuncture in Right Arm" [sic] as well as "Hemoglobin and Hematocrit lab draws every 6 hours" [sic], as ordered by the providers for one (1) of one (1) patients sampled (Patient #1).

The findings include:

On 06/26/23 at 3:14 pm Staff Member #1 (Quality Improvement Director) assisted the surveyor in reviewing the patient-related complaint and grievance records for time frame of 05/01/23 through 06/26/23. On page three (3) of the document, the surveyor identified a documented complaint involving Patient #1 occurring on 05/14/23 [ID # 1227504] involving "Care/Treatment" issue.

On 06/26/23 at 10:17 am the surveyor initiated the review of Patient #1's medical record with the assistance of Staff Member #1, 5, and 9. During review, the surveyor discovered the following information:

Patient #1 presented to the facility's Emergency Department (ED) for fatigue and abdominal pain following referral from an outpatient oncology facility for the treatment of colon cancer. The patient was ultimately admitted to the intensive care unit of facility with a diagnosis of "mesenteric venous thrombosis".

[Note: According to "Healthline" online medical database, a mesenteric venous thrombosis can be described simply as a blood clot located within the veins of the bowel.]

During medical record review, the order set information was reviewed. The surveyor identified two (2) orders that were not followed as written:

1. "No BP, IV, or Venipuncture Right Arm" order was placed by the provider (Staff Member #22) on 05/05/23 at 6:33 pm. Under "Comments" section, the provider indicated that such procedure was according to "PICC Protocol".
The surveyor confirmed that the facility policy titled, "Central venous access catheter blood sampling" (with last revision date of 08/19/22) read in part, "A central venous access catheter provides easy access for blood sampling and spares the patient the pain and anxiety associated with venipunctures ...".
The facility staff assisting with the medical record review confirmed that blood pressures, intravenous catheters or venipunctures performed on the same side of a patient's PICC line is contraindicated to facility procedures.
The surveyor confirmed that Patient #1's medical record documented a PICC line placement on 05/05/23 at 6:20 pm to the right arm which remained until the day of discharge on 05/19/23 when it was removed.

The surveyor conducted interview with Staff Members #6, 12, and 15 (Patient Advocacy) on 06/27/23 at 3:00 pm. The surveyor received confirmation that a night-shift phlebotomist (Staff Member #17) had acquired labs by "sticking" the patient's right hand on 05/14/23. The surveyor confirmed that the ordered labs were not acquired by nursing staff from the PICC line, per facility best practice procedures.
Although the phlebotomist could not be interviewed, the surveyor conducted telephone interview with Staff Member #16 (lab manager) on 06/27/23 at 3:14 pm. Lab manager confirmed that phlebotomist are not authorized to acquire lab samples from a PICC line but they know not to stick patients on same side as PICC line, "as indicated by signage on the wall of [Patient #1's] room." [sic]

Staff Member #16 added that following complaint from family members, the facility became aware of the improper clinical practice, and addressed follow-up education with the phlebotomist. Additionally, Staff Member #16 and Staff Member #1 confirmed that nursing staff should have been contacted to acquire the lab sample from the patient's PICC line instead.

2. Order for "Hemoglobin and Hematocrit labs draws every 6 hours" was placed by the provider, starting on 05/13/23 at 11:00 pm for a duration of "3 days". Staff Member #1 confirmed that the order should have been initiated on 05/13/23 at 11:00 pm and followed through 05/15/23. The surveyor reviewed the Hemoglobin and Hematocrit laboratory results for Patient #1 generated between the dates of 05/13/23 through 05/15/23 and found the following draw times:

05/13/23 at 10:48 pm
05/14/23 at 4:00 am
05/14/23 at 9:45 am
05/14/23 at 8:55 pm
05/15/23 at 4:10 am
05/15/23 at 10:08 am
05/15/23 at 7:50 pm

In the afternoon of 06/28/23, the surveyor inquired if the facility was aware of a reason for the late and/or missing lab draws. Staff speculated they may have been attributed to "poor staffing" within the lab and nursing departments at the time of Patient #1's hospitalization.

The concerns were discussed with Staff Member #1 in the morning of 06/28/23, and again during exit conference on 06/28/23 at 1:15 pm with Staff Members # (1-8).