HospitalInspections.org

Based on interview and document review, it was determined for 1 of 1 (Pt #1) patient who sustained an adverse outcome related to the use of a Vascular Access Device/Central Venous Catheter (VAD - a catheter that is passed through a large vein and the end sets at the opening of the right atrium of the heart/CVC *used interchangeably*), the Hospital failed to ensure staff were knowledgeable and qualified in the provision of care for patients with a VAD. As a result, the Condition of Participation of Emergency Services 42 CFR 482.55, was not met. This has the potential to affect all inpatients and outpatients serviced by the Hospital in which a VAD is utilized. Currently services 10 (ten) inpatient days per month and an unknown number of outpatients (has not been tracked).

Findings include:

1. The Hospital failed to ensure staff were knowledgeable and qualified in the provision of care for patients with a VAD. See deficiency cited at A-1112.

An IJ began on 1/11/17 after Pt #1 presented to the Hospital Laboratory for outpatient laboratory testing. Pt #1 had a "catheter" for dialysis (A dialysis catheter is used for exchanging blood to and from a Hemodialysis machine and a patient. It has two lumens: a venous, that is typically blue, and an arterial, that is typically red). Nursing documentation stated the Registered Nurse (RN) (E#7) was called to the Laboratory to draw laboratory tests via a dialysis catheter. E#7 accessed the dialysis catheter/VAD, flushed with normal saline, withdrew waste blood and then labs, flushed with normal saline, attached heparin syringe. Pt #1 became short of breath and "gasping for breath". A Rapid Response Team was called and within a minute, Pt #1 "was blue and looked like(Pt #1) was mottling" and a Code Blue was called. Pt #1 was revived, intubated (a breathing tube placed for mechanical breathing), underwent computed tomographys of the brain and of the chest, and was transferred to an outlying Hospital (Hospital #2) with the diagnoses Air Embolism of head, Pulmonary Edema, and possible Small Pulmonary Embolism in Peripheral Areas. Pt #1 expired 1/22/17. The record lacked documentation of a physician order to utilize the dialysis catheter/VAD and lacked documentation as to which color of the dialysis catheter was used.

The IJ was identified on 2/21/17 at 3:15 PM and announced during a meeting with the Chief Executive Officer (E#4), the Chief Nursing Executive (E#1), and the Director Care Management and Clinical Documentation Improvement (E#3).

On 2/22/17 the Hospital presented a plan of correction that included revision to the VAD/CVC Policy and Protocol Grid to include the instruction that an order to use the VAD will be required prior to any access, flush, line draw, medication, or injection.

Updated/changed policy placed on the employee portal on 2/21/17 for immediate access by all staff.

Nursing, Laboratory, Radiology, and Physicians to be educated on the policy change, expectation, and process to obtain order if not present via 1:1 education followed up with email notification of changes to begin 2/21/17 with completion date of 2/23/17. Process in place ensuring only qualified personnel access VAD/CVC. Forms containing signatures of completed staff education presented.

Concurrent audit of 100% of charts will be completed of patients who present with VAD to verify a physician order is present to access, flush, line draw, medicate, or inject prior to use.

Audit data will be presented and shared with organization leadership at Quality council as performance improvement project by the senior director of Acute Care Services.

"PATIENT NOTICE For Your Safety If you have a Venous Access Device:..." signage has been placed in Laboratory, Radiology, Patient Access, Surgery Holding Area, Endoscopy Holding Area, and Outpatient Room areas alerting to change in policy.
Staff interviews completed related to the completion of staff training with new VAD/CVC process. Record reviewed of one outpatient who presented for laboratory testing and required an order to utilize the VAD.

Based on the plan of correction presented, observation of signage, staff interview and record review, the IJ was abated on 2/23/17 at 4:05PM, however the Condition of Participation for Emergency Services, 42 CFR 482.55, remains out of compliance.

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient who sustained an adverse outcome related to the care of a Vascular Access Device (VAD), the Hospital failed to ensure staff were knowledgeable and qualified in the provision of care for patients with a VAD. This was evident for 3 of 4 (E#7, #9, and #11) Registered Nurses (RNs) who care for patients with VADs. This has the potential to affect all inpatients and outpatients serviced by the Hospital, which currently services an average of 10 (ten) Inpatient days per month, in which a VAD is utilized and an unknown number of outpatients (as has not been tracked).

Findings include:

1. The policies titled "Central Venous Catheter Policy and Protocol Grid", "Central Venous Catheter (CVC) Care", "Central Venous Catheter Dressing Change and Removal of Central Venous Catheter", and "Outpatient Therapeutic Services" were reviewed on 2/21/17 at approximately 12:00 PM with the Chief Nursing Executive (E#1). Each stated it was a "Patient Services Organization" policy.

An interview was conducted with the Chief Nursing Executive (E#1) during the policy review. E#1 stated "The policies are Patient Service Organizational policies, which means they are for all the areas of the Hospital. No matter where the patient is, whether they are an inpatient, outpatient, lab (laboratory), or whatever, there should be a physician order for the nurse to use the site (CVC access) for anything. CVC covers all the types of accesses, like the implanted ports, PICC (peripherally inserted central catheter), and such. Our policies don't come out and say that, except with the insertion, but that's our expectation. The nurses should always look for an order to make sure they could use the site (CVC/VAD) and what to flush with. As for dialysis catheters, we should never use them for anything."

2. Pt #1's record was reviewed throughout the day of 2/21/17. Pt #1 presented to the Hospital Laboratory for outpatient laboratory testing on 1/11/17. Pt #1 had a "catheter" for dialysis (A dialysis catheter is used for exchanging blood to and from a Hemodialysis machine and a patient. It has two lumens: a venous, that is typically blue, and an arterial, that is typically red). Nursing documentation stated the Registered Nurse (RN) (E#7) was called to the Laboratory to draw laboratory tests via a dialysis catheter/VAD. E#7 accessed the dialysis catheter, flushed with normal saline, withdrew waste blood and then labs, flushed with normal saline, attached heparin syringe. Pt #1 became short of breath and "gasping for breath". A Rapid Response Team was called and within a minute, Pt #1 "was blue and looked like(Pt #1) was mottling" and a Code Blue was called. Pt #1 was revived, intubated (a breathing tube placed for mechanical breathing), underwent computed tomographys of the brain and of the chest, and was transferred to an outlying Hospital (Hospital #2) with the diagnoses Air Embolism of head, Pulmonary Edema, and possible Small Pulmonary Embolism in Peripheral Areas. Pt #1 expired 1/22/17. The record lacked documentation of a physician order to utilize the dialysis catheter/VAD and lacked documentation as to which color of the dialysis catheter was used.

3. Staff interviews were conducted on 2/2/1/17 between approximately 9:30 AM and 10:55 AM with the RNs involved in Pt #1's care, the Chief Nurse Executive (E#1), and the Director of Care Management and Clinical Documentation Improvement (E#3). E#1 was present for each interview. The following were noted:
a. Three of four (E#7, E#9, and E#11) RNs stated one or more of the following: Performs VAD access, laboratory draws, and/or discontinuation on an average of daily to weekly. Relies on Laboratory and/or Radiology staff to have orders to use the VAD; relies on patient to state whether VAD can be utilized; and don't check for a physician order to use the VAD.
b. E#1 stated the Hospital has "started a Root Cause Analysis (RCA) (on Pt #1's care) but have not completed it in total. We do know competencies on VADs are needed. We do one (a competency) on hire and annually, but we haven't done one yet until we finish the RCA."
c. E#3 stated "There's an inconsistent process related to VADs and their use to draw labs and/or access them for a procedure and we've identified that." E#3 verbally agreed no changes in education have been made at this time "until we finish the RCA".