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Based on record review and staff interviews it has been determined that the hospital failed to meet the Conditions of Participation relative to surgical Services, for 1 of 2 patients reviewed related to insertion of an arterial/venous catheter, Patient ID # 1, who retained a guidewire following the procedure. The hospital failed to assure maintenance of high standards of medical practice and patient care and assure that acceptable standards of practice are followed.
(Refer to 951).

Based on record review and staff interviews, it has been determined that the hospital, Our Lady of Fatima Hospital, failed to provide treatment in accordance with acceptable standards of practice and adhere to principles known to decrease the incidence of complications related to a patient retaining a guidewire following the insertion of a femoral arterial/venous catheter for 1 of 2 patients reviewed who had an arterial/venous catheter, Patient ID#1.

Findings are as follows:

Review of Patient ID# 1's medical record obtained from Hospital B, reveals the patient had been transferred from Our Lady of Fatima Hospital to Hospital B on 12/17/2022. The transfer was facilitated by Our Lady of Fatima Hospital after identifying the patient had a recent surgical procedure at Hospital B which may have been a precipitant to current symptoms. Upon arrival to hospital B, an assessment was performed by the Resident Physician, who documented the patient was observed to have a guidewire retained from a previous procedure performed at Our Lady of Fatima Hospital on 12/17/2022, to obtain venous access in the femoral vein performed at Our Lady of Fatima Hospital.

According to the National Library of Medicine, The Seldinger technique is performed by accessing the blood vessel with a needle, feeding a guidewire through the lumen of the needle, and finally placing the catheter in the lumen of the blood vessel by feeding it over the guidewire and removing the guidewire leaving only the catheter itself in place.

During an interview on 12/28/2022 at approximately 2:30 PM, with the Emergency Department Physician (Staff D) employed at Hospital B, where the patient had been transferred on 12/17/2022, he stated that upon the patient's arrival to the emergency department, the Resident Physician, whom Staff D was supervising completed an assessment of Patient ID# 1. The Resident Physician removed the patients pressure dressing located in the groin area to obtain a blood sample from the port. The Resident Physician Informed her supervisor, Staff D that she had observed the guidewire still in the patient. Staff D informed the Resident Physician to slowly remove the guidewire and apply pressure to the area. The wire was removed and discarded.

During an interview on 12/28/2022 at approximately 3:15 PM, with the Emergency Department Physician (Staff E) at Our Lady of Fatima Hospital, where the femoral catheter was placed on 12/17/2022, he stated that he was attempting to obtain venous access in Patient ID# 1, via use of a guidewire, according to the National Library of Medicine, The Seldinger technique is performed by accessing the blood vessel with a needle, feeding a guidewire through the lumen of the needle, and finally placing the catheter in the lumen of the blood vessel by feeding it over the guidewire and removing the guidewire, leaving only the catheter itself in place. He then indicated once the catheter was in the patient, he suspected it was in the arterial artery. He stated he would normally take the catheter out after identifying this but felt the patient's condition was very compromised and decided to leave the arterial line in place. Staff E stated that he ordered a Cat Scan to check the placement of the catheter. Staff E stated he reviewed the Cat Scan report completed by Radiologist, Staff C, which indicated there were no abnormalities noted. The patient was then transferred to Hospital B as planned for ongoing treatment. He was unable to explain why the guidewire was not removed from the patient.

During an interview on 12/28/2022 at approximately 12:00 PM with the Our Lady of Fatima Hospital, Radiologist, Staff C, who had interpreted the scan prior to Staff E's review on 12/17/2022. He stated that the density of the wire and the density of the catheter are the same and therefore it was not identified when he interpreted the Cat Scan.

During an interview on 12/29/2022, with the Our Lady of Fatima Hospital, Radiology Supervisor MD, Staff F, he stated that he reviewed that Cat Scan prior to this interview and indicated that he was able to identify 2 objects, presumably the catheter, and the guidewire, one inside of the other. He acknowledged this finding should have been identified by the physician who reviewed the Cat Scan on 12/17/2022 and should have been identified in the final report.