HospitalInspections.org

The facility failed to meet the regulatory requirements for the Condition of Participation: §482.22 Medical Staff as evidenced by:

Based on interview and record review, the facility failed to ensure one of three sampled patients (Patient 1) had the correct central line catheter (CL-an IV [intravenous] line inserted into a large blood vessel near the center of the body) for hemodialysis (remove waste products and excess fluid from the blood when the kidneys stop working properly) inserted.

This failure resulted in Patient 1 having a second procedure to remove the incorrect central line and for the insertion of the correct CL for dialysis, which had the potential for delayed emergency dialysis. (Refer A-0347)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure safe quality healthcare in compliance with Conditions of Participation for Medical Staff.

Based on interview and record review, the facility failed to ensure one of three sampled patients (Patient 1) had the correct central line catheter (CL-an IV [intravenous] line inserted into a large blood vessel near the center of the body) for hemodialysis (HD - remove waste products and excess fluid from the blood when the kidneys stop working properly) inserted. This failure resulted in Patient 1 having a second procedure to remove the incorrect central line and for the insertion of the correct CL for dialysis, which had the potential for delayed emergency dialysis.

Findings:

During an interview on 12/2/24 at 3:30 p.m. with Patient 1, Patient 1 stated he did not know why he had to have the catheter in his neck replaced. Patient 1 stated he did not recall the hospital telling him that they had made a mistake.

During a review of Patient 1's "INFORMED CONSENT FOR SURGICAL, DIAGNOSTIC OR THERAPEUTIC PROCEDURE (REV[ISED] 5/2024" the consent indicated, "I, [Patient 1], authorize and request (Post Graduate Year [PGY] 1 - a recent graduate from medical school in his/her 1st year of training) and associates of his/her choice and appropriate hospital personnel, including Advanced Practice Providers, to assist in performing the following medical/surgical procedure(s) on me: Vas-cath insertion [Vascular Catheter is a flexible tube inserted into a large vein typically in the neck or groin in situations requiring temporary dialysis for patients in kidney failure]" insertion, dated and signed by Patient 1 on 10/14/24 at 8:21 PM.

During a review of PGY 1's "ED Procedure Note" dated 10/14/24 at 10:28 PM, the note indicated under the procedure subheading, "Right IJ [Internal Jugular vein located on the side of the neck] Vas Cath Central Line Procedure Note. . .Indication: Emergent dialysis. . .Site: Internal Jugular Vein. . .Catheter type: Triple lumen [three channels and lumens] 7F [French - a unit of measurement for catheter size] vas cath. . ."

During a concurrent interview and record review on 12/2/24 at 3:40 p.m. with the Chief Nursing Officer (CNO), Nurse Practitioner (NP) 1's "Critical Care/Intensivist Procedure (CCIP)" note dated 10/15/24 at 3:15 a.m., indicated "Noticed Central Line 7F triple lumen 16cm [centimeters - length of catheter] was inserted in the RIJ instead of HD [hemodialysis] cath[eter]. Patient [1] has Emergency HD for uremia [buildup of waste products in your blood that occurs as a result of untreated kidney failure, without treatment uremia is fatal] and acidosis [build up of acid in the body as result of kidney failure]. . . Emergent catheter exchange was needed. . .Procedure Performed: central line exchange to Trialysis/Hemodialysis Line Placement R [Right] IJ. . .Pre-procedure diagnosis: urosepsis [life-threatening medical condition that occurs when a urinary tract infection spreads to the bloodstream and causes sepsis which is a dangerous response by the body to an infection that can lead to death] metabolic acidosis. . .Post-procedure diagnosis: urosepsis metabolic acidosis. . .Informed consent: Implied Emergent. . ." Patient 1 was informed about risks, benefits, and alternatives prior to signing the consent for the exchange of the CL's. The CNO stated the disclosure of the error to the patient was not documented.

During an interview on 12/3/24 at 11:30 a.m. with PGY 1 and Doctor of Osteopathy (DO) 1, PGY 1 stated she was asked to put in a Vas Cath for Patient 1. PGY 1 stated she removed a kit that she believed was a Vas Cath kit from the CL cart. PGY 1 stated the team did a time-out (a short pause prior to a procedure to confirm the correct patient, procedure and site) , but no one noticed the kit was not a Vas Cath kit. PGY 1 stated the procedure went well but she was not aware the incorrect catheter was inserted. DO 1 stated he was supervising PGY 1. He stated during the time out, he did not realize PGY 1 had the wrong CL kit.

During an interview on 12/4/24 at 2:30 p.m. with the Director of Critical Care (DCC), the DCC stated she was involved in the investigation of the placement of the incorrect CL. DCC stated a CL not designed for hemodialysis was inserted into Patient 1 instead of a Vas Cath. DCC stated the facility had kits for both CL and hemodialysis that looked alike and the CL cart was not labeled effectively.

During a review of Patient 1's "Preprocedure [sic] Time-Out Universal Protocol (TOUP)," dated 10/14/24, the TOUP indicated, "Procedure Category ... Line Insertion, Other: vas cath insertion ... Product verified by proceduralist ... yes ... Name of Product Read Aloud ...Yes."

During a review of Patient 1's "ED Procedural Note (EDPN)," dated 10/14/24, the EDPN indicated, "Procedure: Right IJ (Internal Jugular - a vein that collects blood from the brain and delivers it to the heart) Vas Cath Line Procedure ... Catheter type: Triple lumen 7 fr vas cath ... a 'time out' was completed to ensure correct patient ... The CVL [central venous line] was inserted ... the guidewire was removed ... A portable CXR [chest x ray] was ordered."

During a review of Patient 1's "Critical Care / Intensivist Procedure (CCIP)," dated 10/15/24, the CCIP indicated, "Noticed Central Line 7F triple lumen 16 cm [centimeter] was inserted in the R [right] IJ instead of HD [hemodialysis -dialysis using blood in the veins] cath. Patient has Emergent HD for uremia [build up of toxins in blood] and acidosis [blood is acidic] ...Emergent catheter exchange was needed ...Procedure Performed: central line exchange to [brand name]/Hemodialysis Line Placement R IJ."

During a review of the facility's policy and procedure (P&P) titled, "Surgical/Procedural Site Verification (Universal Protocol)," approval date 1/10/20, the P&P indicated, "Procedure: I. Conduct a preoperative/pre-invasive procedure verification process in all settings ... B. A preoperative/preprocedure [sic] verification checklist (hard copy or electronic) is used to review and ensure availability of the following items prior to the start of the procedure. The electronic verification checklist is retained as part of the medical record ... 4. Confirming the on-site availability of any required implants, devices, and/or special equipment for the procedure."

During a review of the facility's P&P titled, "Sentinel Event and Adverse Event Response and Reporting," approval date 11/20/23, the P&P indicated, "PROCESS for Sentinel/Adverse events and near-misses ... G. The RM [Risk Management] Director (or designee) in collaboration with the patient's physician, Chief of Staff (or designee) will ensure that an apology is offered and notice of the SE/AE [sentinel event/adverse event] is given to the patient involved, or the party responsible for the patient, of the nature of the Event by the time the initial report is made to CDPH [California Department of Public Health]."

The facility failed to meet the regulatory requirements for the Condition of Participation: §482.23 Nursing Services as evidenced by:

Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 14) was provided safe, competent nursing care when licensed nursing staff were not trained and evaluated for competency prior to inserting and using the post pyloric tube (PPT - tube inserted through the nose past the stomach to deliver nutrition and medications).

This failure resulted in Patient 14 having an unintentionally retained stylet/guidewire which has the potential for significant negative health outcomes. (Refer to A-0385)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure safe quality health care, in compliance with Conditions of Participation for Nursing Services.

Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 14) was provided safe competent nursing care when licensed nursing staff were not trained and evaluated for competency prior to inserting and using the post pyloric tube (PPT - tube inserted through the nose past the stomach to deliver nutrition and medications). This failure resulted in Patient 14 having an unintentionally retained stylet/guidewire which has the potential for significant negative health outcomes.

Findings:

During a review of Patient 14's "History and Physical (H&P)," dated 10/4/24, the H&P indicated Patient 14 was brought to the emergency department (ED) with concerns of altered mental status. Patient 14 had a history of cerebral palsy (abnormal brain development disorder affecting movement), developmental mental delay, upper and lower extremity contractures (tightening of muscles), seizure disorder (abnormal electrical activity of the brain causing uncontrolled movements or loss of conciousness) and was non-verbal. A Computed Tomography (CT x-ray images of the body) of Patient 14's abdomen was done and indicated concern for possible rectal cancer.

During a review of Post Graduate Year ([PGY] 2 - a recent graduate from medical school in his/her 3rd year of training) "ED (Emergency Department) Note Physician *Final Report*", dated 10/4/24 at 2:03 PM, the note indicated, ". . . I have assumed care of this patient. . .Workup thus far reveals sepsis (life threatening medical condition due to an extreme response to an infection). . .Dx'd (diagnoses) with a "tia [Transient Ischemic Attack - mini stroke] yesterday was discharged from the floor. Anticipated disposition is admit. . ."

During a review of the "ORDER SHEET", the Order Sheet dated 10/5/24 at 9:02 a.m., indicated, "Post Pyloric Feeding Tube Insertion." On 10/5/24 at 9:02 a.m., the Order Sheet indicated, "Post Pyloric Feeding Tube Care. . .Confirm Placement with XR [x-ray] abdomen 1 view (KUB [Kidney Ureters Bladder]). . .After KUB confirmation remove metal stylet [guidewire] and keep at bedside. . .Ensure metal stylet is removed prior to sending patient to MRI. . .May reinsert metal stylet if tube gets slugglish/clogged. . ."

During a review of the "[GI Tube] Flowsheet (GITF)," dated 10/6/24 through 10/19/24, the GITF indicated on 10/6/24 at 1 p.m., Registerd Nurse (RN) 1 inserted a small gauge tube (PPT) through Patient 14's right nare (opening of nose).

During a review of the "XR Abdomen KUB 1 View *Final Report*" dated 10/6/24 4:18 PM, indicated, "HISTORY. . .POST PYLORIC PLACEMENT. . .FINDINGS: There is a Dobbhoff tube seen, tip projecting over the left upper quadrant. . ."

During a review of Patient 14's Order Sheet dated 10/6/24, the OS indicated, "Tube Feeding Continuous. . . Nasogastric [PPT], Jevity [type of liquid nutrition] 1.2 Cal [calories], 24 hours, Start at 20 mL [milliliters]/hr [hour] and advance 10 mL q [every] 10 hr to goal rate of 50 mL x 24 hr/day."

During a review of the 10/16/24 at 11:59 a.m. "Adult Systems Assessment", the Assessment indicated, "Unexpected Event. . .Other: guidewire in place since 10/6/24. . ."

During a review of the "GITF," dated 10/17/24 at 9:34 a.m., the GITF indicated, "Gastrointestinal Tubes. . . Unexpected Event Other: guide wire [sic] in place since 10/6/24."

During an interview on 12/2/24 at 3:04 p.m. with Registerd Nurse (RN) 1, RN 1 stated she inserted Patient 14's PPT on 10/6/24. RN 1 stated she was able to insert the PPT but not in the correct position and informed the oncoming nurse but Physician (MD) was not notified. On 10/7/24, RN 1 received report the PPT was not advanced to place in the correct position. RN 1 notified MD who indicated to start the nutrition. She was aware the stylet (guidewire) was still in the PPT. On 10/8/24, RN 1 gave report to the night shift nurse informing the nurse of the need to remove the stylet if the patient was required to go for an Magnetic Resonance Imaging (MRI is a non-invasive imaging technique that uses radio wave and a powerful magnet to create detailed pictures of the inside of the body). RN 1 did not recall having training on insertion or use of the PPT product. RN 1 stated she did not notify MD of the guidewire remaining in the PPT when the nutrition was started.

During an interview on 12/2/24 at 3:20 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 10/17/24, he was preparing to administer Patient 14's medication through the PPT, when he prepared to flush with a syringe the stylet came back into the syringe. LVN 1 stated he discovered the guidewire still in Patient 14's PPT on 10/17/24. LVN 1 stated he received assistance from RN 3, who successfully removed the guidewire.

During an interview on 12/2/24 at 3:48 p.m. with Nurse Manager (NM) 1, NM 1 stated stated the guidewire was not to be left in the PPT while being used. NM 1 stated the guidewire was left in place in Patient 14's PPT for 11 days.

During an interview on 12/2/24 at 3:50 p.m. with Director of Medical Surgical Unit (DMS), DMS stated the PPT product is part of our new hire orientation, but not part of our annual competencies.

During a concurrent interview and record review on 12/3/24 at 4:29 p.m. with Director of Talent Acquisition (DTA), RN 1's personnel file (PF) was reviewed. The PF indicated RN 1 had a discussion for PPT insertion on 8/5/24. DTA stated the new hire competency checklist did not include documentation of training for guidewire removal and no demonstration of competency.

During an interview on 12/3/23 at 10:09 a.m. with RN 2, RN 2 stated she assumed care of Patient 14 and did not recall having training for this type of PPT and had not inserted a PPT before.

During a concurrent interview and record review on 12/3/24 at 4:37 p.m. with DTA, RN 2's PF was reviewed. DTA stated the medical surgical core competencies are different since RN 2 was a traveler. DTA stated travel nurses come from their company with a checklist of competencies and the hospital has an abbreviated competency check list for travelers. DTA stated RN 2 did not have training for use of the PPT.

During a concurrent interview and record review on 12/3/24 at 1:55 p.m. with Director of Clinical Education (DCE), the hospital's "Medical Surgical Orientation Competency Checklist: Licensed Nurse and Student Nurse Intern (MSCC)," (undated) was reviewed. The MSCC indicated training for PPT insertion. DCE stated the checklist did not include guidewire removal before use.

During a concurrent interview and record review on 12/3/24 at 2:33 p.m. with DCE, the hospital's "Annual Competency 2024 3 South Medical Surgical (AC)," dated 2024, was reviewed. DCE stated training for PPT use was not included in the AC.

During an interview on 12/4/24 at 9:05 a.m., with Physician (MD), he stated he did not recall being notified the stylet was retained and had not been removed when the nutritional feeding was started. When he placed the order (10/5/24) to start the feeding, he would have expected the stylet to have been removed due to possible occlusion, improperly functioning tube and aspiration.

During a review of the hospital's P&P titled, "Nutrition: Enteral Nutrition," dated 10/30/23, the P&P indicated, "General Enteral Nutrition Management: . . . II. . . B. Small bowel/post-pyloric tubes: 1. Ensure that the metal stylet [guidewire] is removed after placement has been verified via radiograph [x-ray]. . . Tube Patency and Flushing Management: I. Prior to instilling nutrition/medications or flushes into any enteral tube the following will be considered: . . . C. Ensure metal stylet has been removed from small bowel/post-pyloric tubes prior to administering nutrition . . . Small Bowel - Post Pyloric Tube Monitoring: II. Insertion of a small bowel/post-pyloric feeding tube will be completed only by licensed staff. A. The metal stylet will be removed immediately after placement has been confirmed via radiograph. 1. . . a. Ensure metal stylet has been removed prior to administering nutrition. . . Potential Complications Non patent/blocked tube. . . F. Stylet still in place. . . E. Discontinue tube and call practitioner for orders."