HospitalInspections.org

Based on record review and staff interviews, it was determined that the hospital failed to ensure that a patient's implanted chest port (a small medical device placed under the skin, usually in the chest, used to deliver medications, fluids, or take blood samples) was properly de-accessed (safely removing the needle that was inserted into the port) before the patient was discharged to a Skilled Nursing Facility which resulted in the patient's return to the hospital for 1 of 4 patients reviewed who were discharged from the hospital with implanted ports in place, (Patient ID #1).

Findings are as follows:

On 5/7/2025, the Rhode Island Department of Health received an anonymous report alleging that Patient ID #1's chest port was still accessed upon his/her arrival to the Skilled Nursing Facility following discharge from the hospital on 5/1/2025.

Record review revealed that the patient was admitted to hospital in April of 2025 for an elective surgical procedure.

The record indicated that on the day of his/her admission to the hospital, the patient had an implanted port on the right side of the chest.

Further record review revealed that on 5/1/2025 at 7:50 AM, Employee A, Registered Nurse (RN) indicated in the "Lines, Drains, Airways" flowsheet that the patient's implanted port was due for a needle and a dressing change.

However, the "Lines, Drains, Airways" flowsheet failed to reveal evidence that dressing was changed or that the needle was either changed or removed on 5/1/2025.

According to the record, the patient was discharged from the hospital and transferred to a Skilled Nursing Facility via ambulance by 12:08 PM on 5/1/2025.

Record review revealed that the patient returned to the hospital at 4:44 PM on the same day of his/her discharge and she/he was seen in the emergency department because his/her chest port was never de-accessed prior to discharge to the Skilled Nursing Facility earlier in the day.

During a surveyor interview on 5/21/2025 at 9:45 AM with Employee A, RN, she indicated that on the day of the patient's discharge, she documented in the "Lines, Drains, Airways" flowsheet that the dressing covering the accessed port needed to be changed that day and then sent the Vascular Access Team (team specializing in providing access into a patient's circulatory system through the insertion of catheters) a "secure chat" informing them of this since she is not certified to change port dressings or port needles. Employee A explained that later in the shift, the ambulance arrived to pick up the patient and she helped the patient settle on the stretcher. Employee A revealed that the Vascular Access Team then reached out to her and asked her if she had de-accessed the patient's port, but by that time the patient was no longer on the unit. Employee A acknowledged that she did not ensure the patient's port was de-accessed before she/he left the unit.

During a surveyor interview on 5/21/2025 at 2:15 PM with Employee B, Vascular Access Team RN, she confirmed that she was on duty on 5/1/2025 and explained that she is usually consulted to de-access implanted ports upon a patient's discharge and usually waits for this request from the patient's nurse. She explained that by the time she rounded on the patient, the patient was gone and so she reached out to the patient's nurse, Employee A, and asked her if the patient's port had been de-accessed. When asked if Employee A reached out to her to de-access the chest port before the patient was discharged, she stated that Employee A did not contact her.

Based on the information reviewed and the staff interviewed, Employee A failed to ensure the patient's chest port was de-accessed before the patient left the hospital. Additionally, there was no evidence that Employee A contacted Employee B to de-access Patient ID #1's chest port prior to discharge.