HospitalInspections.org

Based on record review and interview the hospital failed to implement corrective actions to ensure staff function in a safe and effective manner after a sentinel event in 1 of 1 sentinel events.

See Tag A-0286

Based on record review and interview the facility failed to implement an action plan and evaluate the plan for effectiveness following a root cause analysis for a retained foreign object in 1 of 1 sentinel events.

Findings include:

Review of Patient #1's medical record revealed that a central line was inserted before surgery on 2/25/2020 by CRNA G. A post placement x-ray was performed which read in part, "the right jugular catheter remains in stable position and appears to be coiled in the right upper quadrant, presumably in the IVC. (inferior vena cava - a vein that is the largest vein in the human body). Alternately this may represent extension of the guidewire terminating into the right upper quadrant. Clinical correlation warranted." In interview with CRNA G on 6/10/2020 at 7:00 AM when asked about the catheter insertion stated, "because of the question on the post placement x-ray the surgeon asked that the catheter not be used until the placement could be confirmed. I capped the line and we did not use it. After the surgery the surgeon consulted with radiology and it was determined that the guidewire had not been removed from the catheter." Medical record revealed that on 2/26/2020 Patient #1 was taken to the Cardiac Cath lab for removal of the catheter and guidewire.

In interview with Quality Manager F and Quality Director A on 6/9/2020 at 3:30 PM Quality Manager F stated that the incident was self reported as a Sentinel Event to (the accrediting organization) and a Root Cause Analysis (RCA) performed on 3/11/2020. Quality Manager F stated that (the accrediting organization) "accepted and approved our action plan on May 13, 2020. We determined the root cause to be human factors." Review of the action plan from the RCA revealed no documentation for the heading "Responsible Party" or "Date Implemented." The plan indicated under "Audit", "100% of charts audited will have addressed each of the items on the checklist for triple lumen catheter placement...Please collect 4 months of data and include the numerator and denominator for each month." Requested from Quality Director A results of the audits from the action plan. She stated, "we haven't done any yet, we were waiting for (the accrediting organization) to approve the plan. They (the accrediting organization) told us that we had a grace period because of the Covid-19 pandemic that was going on, plus we need to have IT (information technology) build the checklist into our system." Questioned regarding education or change in practice since the 2/25/2020 event Quality Director A stated, "I'm sure we mentioned it to the surgery department but we haven't formally instituted any changes."

Review of facility policy 5156388 "Sentinel Event" last revised 7/2015 revealed, in part, "an event is also considered sentinel if it is one of the following...unintended retention of a foreign object in a patient after an invasive procedure... Such events are considered "sentinel" because they signal a need for immediate investigation and response." Under "Procedure" of the policy it states, in part, "a determination of potential improvement in processes or systems that would tend to decrease the likelihood of such events in the future, or a determination, after analysis, that no such improvement opportunities exist... The action plan must address the following: action to be taken, responsibility for implementation, time lines, strategies for evaluating the effectiveness of actions, strategies for sustaining the change."