HospitalInspections.org

Based on medical record review, interview and policy review, the facility failed to ensure that medical records were accurately documented for 1 of 1 Patient reviewed (#1) with a central venous catheter.

Specifically,
1. Patient #1's central venous catheter was referred to by various names/types in the electronic medical record documentation including Peripherally Inserted Central Catheter (PICC), Hickman catheter and Quinton Catheter and,

2. Documentation on 06/15/20 by a nurse regarding insertion of a tunneled right subclavian catheter was unclear as to who inserted the line and the actual date of insertion.

As a result, the documentation was unclear to anyone reviewing the electronic medical record to determine the type of catheter/s present.

Findings Include:

1. Medical Record Review

Review of the electronic medical record for Patient #1 on 02/01/21 revealed the following in part:

On 06/05/20 at 11:12 a.m. a radiologist noted the following in his report: "Exam: Central Venous Line (Not PICC)," "Micropuncture needle and ultrasound guidance used to enter the right internal jugular vein" and
"Impression: successful tunneled right IJ 6 French PICC line placement."

On 06/06/20 at 2000, Nurse A noted under "Lines" "hickman catheter chest right."

On 06/07/20 at 1047, Nurse B noted under "Lines" "hickman catheter chest right."

On 06/08/20 at 2241, Nurse C noted under "Lines" "hickman catheter chest right."

On 06/11/20 at 2:20 p.m. a chest x-ray report noted, "Right tunneled PICC terminates in the mid SVC."

On 06/15/20 at 2000, Nurse D noted under "Lines," "1200 PICC multi lumen double Subclavian Right Inserted. Tunneled. Procedure Consent Obtained/on chart: yes. Inserted by, if other than current documenter: Nurse ..."

0n 07/14/20 (date of discharge), at 0800, Nurse E noted under "Lines," "PICC multi lumen double Subclavian Right Inserted 06/15/20 1200. Non tunneled." At 1630, Nurse E (same nurse who made the prior entry) noted in "Nursing Notes," "Hickman line remained intact from right chest."

On 07/25/20 (date of re-admission) at 4:02 p.m. a chest x-ray report noted, " ...right central line tip in the SVC."

On 07/26/20 at 0345, Nurse F noted in "Nursing Notes," "IV access noted: Quinton Right Chest ..."

On 07/26/20 at 1600, Nurse G noted in a "Critical Care Flowsheet Lines," "Dialysis catheter double Subclavian Right Inserted 07/24/20 0700. ...present on arriv..." and "Criteria for continuing central line: Temporary dialysis access."

On 07/31/20 at 4:07 a.m. a chest x-ray report noted, "Right IJ catheter tip is in the cavoatrial junction. PICC line tip in the SVC ..."

2. Interview

During an interview with the Chief Nursing Officer, Quality Coordinator and Sepsis Coordinator in a conference room on 03/04/21 at 1:57 p.m., the electronic medical record for Patient #1 was reviewed. After their own review of the medical record, the Chief Nursing Officer, Quality Coordinator and Sepsis Coordinator acknowledged the nursing documentation about the line was confusing and attributed it to the platform in the electronic medical record that the nurses use for the documentation of lines. The following are specific examples of specific nursing documentation that were reviewed and discussed during the interview.

The Chief Nursing Officer, Quality Coordinator and Sepsis Coordinator were asked to review the entry on 06/15/20 at 2000, in which Nurse D noted under "Lines," "1200 PICC multi lumen double Subclavian Right Inserted. Tunneled. Procedure Consent Obtained/on chart: yes. Inserted by, if other than current documenter: Nurse ..." They confirmed that on 06/15/20 the nurse documented the insertion of a "PICC multi lumen double Subclavian Right, tunneled" and "Inserted by, if other than current documenter: Nurse." But according to the Chief Nursing Officer, nurses do not insert central venous catheters, they do not insert subclavians or IJ's (internal jugular) and they do not remove tunneled lines.

The Chief Nursing Officer, Quality Coordinator and Sepsis Coordinator were asked to review the Critical Care Flowsheet Lines dated 07/26/20 at 1600 by Nurse G that noted, "Dialysis catheter double Subclavian Right Inserted 07/24/20 0700. ...present on arriv..." and "Criteria for continuing central line: Temporary dialysis access." They were asked where the insertion date of "07/24/20" came from. The patient had been re-admitted to the hospital on 07/25/20. Neither the Chief Nursing Officer, Quality Coordinator nor the Sepsis Coordinator could identify where the date of "07/24/20" came from.

3. Policy Review

The facility policy entitled, "Central Venous Catheter (CVC) Management for the Adult Patient," with a last revised date of "12/2020" was reviewed on 03/02/20 and stated the following in part:

DEFINITIONS:
Nontunneled CVC: Percutaneously inserted into the internal jugular, subclavian or femoral vein.
Tunneled: Implanted into internal jugular, subclavian or femoral vein ...
Peripherally Inserted Central Catheter (PICC): Percutaneous insertion into the basilic, brachial or cephalic vein and enters the superior vena cava.

1. PROCEDURE: Insertion of CVC
...
1.0.0.1. Ensure consent has been properly executed with all appropriate signatures prior to CVC insertion ...

5. Document the procedure in the electronic medical record including the date, time, and name of the person inserting the central line, type of catheter, size of the catheter, location, internal length, external length, baseline arm circumference at insertion site (for PICC catheters), how patient tolerated procedure, indication for insertion, and patient eduction (sic).

6. Patient admitted with a CVC - Upon admission at first access ... ...
e. Document in the medical record the type and size of the CVC, date of insertion, name of practitioner who placed the catheter (if known), procedures performed, and the findings of the site assessment ...