HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by:

1. Failure to ensure care plans were implemented (Refer to A-396);

2. Failure to follow hospital policy and procedures when removing an arterial line (a thin catheter inserted into an artery for blood pressure monitoring or taking blood samples). Nursing staff cut Patient 7's arterial line causing it to become retained in the radial artery (Refer to A-398); and

3. Failure to follow hospital policy and procedures in placing a barrier in between patient's orogastric tube (OG tube, a tube inserted through the mouth that goes directly into the stomach to provide nutrients and medication) and skin, which resulted in a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) (Refer to A-398).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the hospital failed to ensure care plans were implemented for three out of 30 sampled residents (Patients 11, 12, and 13) when there was no documentation indicating care plans had been initiated upon admission. This failure had the potential for the patients' needs not being met and worsening clinical condition.

Findings:

Review of Patient 11's inpatient history and physical (H&P, a document where providers document the patient's medical history and the treatment plan for the patient), dated 1/6/25, indicated the patient was admitted on 1/6/25 with a diagnosis of blastic plasmacytoid dendritic cell neoplasm (a rare form of cancer, a disorder of cell growth), and placement of a tunneled central venous catheter (a tube that goes directly in a large vein close to the heart, for delivering intravenous medication).

During a concurrent interview and record review with Performance Improvement Specialist (PIS) H on 1/22/25 at 2:55 p.m., Patient 11's flowsheet data was reviewed from 1/6/25 to 1/22/25. The flowsheets dated from 1/6/25 to 1/22/25 showed there was no care plans implemented for Patient 11 on 1/6/25, the day of admission. PIS H also stated care plans should be initiated within 24 hours of admission.

Review of Patient 12's inpatient H&P, dated 1/3/25, indicated the patient was admitted on 1/3/25 with a diagnosis of chronic myeloid leukemia (CML, a type of cancer of the blood cells) and placement of a tunneled central venous catheter.

During a concurrent interview and record review with PIS H on 1/22/25 at 2:55 p.m., Patient 12's flowsheet data was reviewed from 1/3/25 to 1/22/25. The flowsheets dated from 1/3/25 to 1/22/25 showed there were no care plans implemented for Patient 12 on 1/3/25, the day of admission.

Review of Patient 13's inpatient H&P indicated the patient was admitted on 11/25/24 with a diagnosis of metastatic neuroblastoma (a type of cancer that is spread out throughout the body) and placement of a tunneled central venous catheter.

During a concurrent interview and record review with the Patient Care Manager (PCM) A, Nurse Educator (NE) B, and the Assistant Patient Care Manager (APCM) on 1/23/25 at 1:06 p.m., all three individuals confirmed there were no care plans in place for Patients 11, 12 and 13.

Review of hospital policy titled "Care Plan", last revised March 2023, indicated, " ...Care plans will be individualized and include information and parameters specific to the interdisciplinary goals identified upon admission ... Care plans must be initiated within 24 hours of admission."

48935

Based on observation, interview and record review, the hospital failed to implement its policies and procedures for three of 25 sampled patients (Patients 2, 7, and 31) when:

1. Nursing staff "accidentally" cut Patient 7's arterial line (a thin catheter inserted into an artery for blood pressure monitoring or taking blood samples) causing it to become retained in the radial artery;

2. Nursing staff placed an orogastric tube (OG tube, a tube inserted through the mouth that goes directly into the stomach to provide nutrients and medication) directly on Patient 2's skin in the chin area;

3. Nursing staff placed an OG tube directly on Patient 31's skin in the right cheek area without a barrier in between the tube and the skin.

These failures resulted in Patient 7 undergoing a surgical procedure to remove the retained arterial catheter and a pressure injury (an injury caused by staying in one position for a long period of time) for Patient 2. The failures also had the potential to lead to the formation of a pressure injury for Patient 31.

Findings:

1. Review of Patient 7's Pediatrics Admission History and Physical (H&P, a document where providers document the patient's medical history and the treatment plan for the patient), dated 2/18/24 indicated the patient was admitted on 2/18/24 with a history of moderate-severe spinal stenosis and lower extremity pain.

Review of Patient 7's Arterial Line Management - Right Radial Order Information, dated 2/28/24 indicated the patient had an order to discontinue the right radial arterial line.

Review of Patient 7's nursing flowsheet, under the provider notification section, dated 2/28/24 at 1:30 p.m., indicated the reason for communication was arterial line removal. It indicated the provider notification details was "Part of catheter remaining in pt [patient] when [removal] attempt. Catheter cut instead of sutures ..."

Review of Patient 7's Progress Notes, dated 2/28/24 indicated, "Earlier today the bedside RN for this patient accidentally transected [cut across] the radial arterial catheter at the hub when she was removing dressings to remove the catheter ... an ultrasound shows the catheter in the radial artery ... We have presented the situation to the family and regret the accident."

Review of Patient 7's Imaging Result (Ultrasound [an imaging test that uses sound waves to look inside the body]), dated 2/29/24 indicated, "Retained radial arterial catheter fragment."

Review of Patient 7's Wrist Xray, dated 2/29/24 indicated, "Linear density measuring 1.9 cm [centimeters, unit of measurement] in length project over soft tissues ... Compatible with provided history of retained arterial line catheter."

Review of Patient 7's Neurosurgery Progress Note, dated 3/1/24 indicated, "MRI and CT on 2/19/24 showed worst angulation of the spine, therefore surgery is recommended to stabilize his spine. He underwent OR [operating room] on Friday 2/23/24 ... For retained artline [arterial line] catheter ... Spoke to vascular and general surgery, who recommended hand surgery. Will continue discussions with hand surgery. Will push out surgery to 1 month postop [after surgery] as we cannot use anticoagulation prior to then ..."

Review of Patient 7's Neurosurgery Discharge Summary, dated 3/6/24 indicated follow up appointments included, "Hand Surgery (remove retained catheter in 1 month)."

Review of Patient 7's Operative Report, dated 4/4/24 indicated the patient underwent open removal of radial artery catheter and radial artery revascularization (a medical procedure that restores blood flow to and organ or other part of a body) with 3 cm reversed vein graft (a medical procedure that removes a vein from one part of the body to another part and allows blood to flow through the valves in the vein).

During an interview on 1/21/25 at 11:59 a.m. the Clinical Nurse Specialist (CNS) stated Registered Nurse I (RN I) was in the process of removing Patient 7's arterial line. The CNS stated RN I anticipated all arterial lines were secured with sutures. The CNS stated Patient 7's arterial line was secured with a stat lock (a medical device that stabilizes catheters and prevents them from being accidentally pulled out) and did not have sutures. The CNS stated RN I used a suture removal kit and cut Patient 7's arterial line, so that was how the catheter fragment remained.

During an interview on 1/21/25 at 1:39 p.m. RN I stated she had orders to remove Patient 7's arterial line. RN I stated she Patient 7 had a stat lock holding the arterial line in place. RN I stated she thought there were sutures below it. RN I stated she cut the catheter when she mistook the catheter for sutures.

Review of the hospital's procedure, "Vascular Access: Peripheral Arterial Lines," dated 10/2023 indicated the procedure for removing peripheral arterial lines (PAL) was the following: "1. Obtain an order to discontinue PAL ... 4. Stop arterial line infusion and clamp the line ... 7. Remove the tap and transparent dressing, using adhesive remover solution... Observe for signs of infection ... 8. Cleanse the site with appropriate antiseptic solution. Remove sutures, if any. 9. Hold sterile 4x4 gauze over the insertion site and remove catheter ... 12. Assess catheter to ensure it is intact ..."

2. Review of Patient 2's H&P, dated 7/11/23, indicated Patient 2 was born on 7/11/23 at 24 weeks gestation because of Patient 2's mother's medical condition. Patient 2 was diagnosed with suspected cardiomegaly (enlargement of the heart) and persistent reversed end diastolic flow (a disorder in the flow of blood to and from the heart).

Review of Patient 2's Pressure Injury Care Consult Note, dated 12/26/23 indicated Patient 2 acquired a pressure injury on 12/23/23 on the right side of the chin, staged at Stage 2 (a stage of pressure injury that indicates the inner skin layer is exposed because of loss of external skin layer). The Pressure Injury Care Consult Note indicated, "Suspected Cause: Device: OG tube under scuba CPAP [continuous positive airway pressure (a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in)] mask." The Pressure Injury Care Consult Note also indicated, "OG tube no longer secured to chin ... Avoid all additional pressure to chin- do not secure OG over chin, please try not to use scuba mask."

Review of a follow up Pressure Injury Care Consult Note, dated 12/28/23, indicated Patient 2's pressure injury staging changed from Stage 2 to unstageable (full-thickness pressure injury in which the base is obscured by dead tissue and the depth of the wound is difficult to determine).

During an interview with RN F on 1/22/25 at 1:16 p.m., RN F said when using the CPAP mask, "We use an Allevyn bandage, pink padded adhesive that is cut by a respiratory therapist, and one is placed by the chin, one across the forehead, and then lining the mask along the cheeks." RN F also stated, "The OG tube is supposed to go down the chin but over the pink padding under the scuba mask so that it's not actually pressing it to the skin."

During an interview with the wound, ostomy, and continence manager (WOCM) on 1/21/25 at 2:08 p.m., the WOCM stated, "The wound was identified as a Stage 2 at first, though it was always on the edge of being unstageable." The WOCM also stated, "The wound was avoidable."

Review of facility policy titled "Pressure Injury-Prevention, Risk Assessment and Maintaining Skin Integrity", last revised October 2021, indicated, " ... Assess skin contact with medical devices each shift or more frequently with care or per policy ..."

3. Review of Patient 31's admission indicated Patient 31 was admitted on 1/17/25.

During an observation on 1/22/25 at 1:32 p.m., Patient 31 was seen lying in a crib, with a continuous positive airway pressure (CPAP, a noninvasive way to help with oxygen delivery and breathing) mask covering the patient's face. A pink barrier was between the CPAP mask and the skin. An OG tube was draped along the right side of face, with the tube sitting on the skin in the right cheek area, under the pink barrier bandage (Allevyn).

During an interview with registered nurse (RN) G on 1/22/25 at 1:34 p.m., RN G said, "The OG tube should be over the Allevyn dressing, not under it."

During an interview with Nurse Educator (NE) D and NE E on 1/23/25 at 1:24 p.m., NE D said an OG tube should be secured in a way "as long as it's not fish hooking around the nare, and then use a duoderm between the skin and the tube." NE E added, "It should be over the Allevyn, and the tube should be secured in a way that it's not over a bony prominence like the cheek. Either with the bandage or duoderm."

Review of facility policy titled, "Enteral Tube Insertion and Management", last revised October 2024, indicated " ...IF placement confirmed, secure tube by: 1) Taping tube to skin protecting barrier ..."