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Based on record review and staff interview, it was determined that the hospital failed to ensure a nurse adhered to the standard of practice for the placement of Peripherally Inserted Central Catheters (PICC), a long and thin tube that is inserted through a vein in the arm that is used to give medications, fluids, or nutrients over a long period of time, which caused the tip of a guide wire to shear off inside of the patient's arm for 1 of 5 patients reviewed (Patient ID #1). This failure resulted in the patient being subjected to an unnecessary surgical procedure as the retained piece of wire had to be surgically removed.

Findings are as follows:

Record review revealed that Patient ID #1 was admitted to the hospital in January of 2025 after presenting to the Emergency Department with complaints of abdominal pain, nausea, vomiting and diarrhea. During his/her admission, the patient was to receive nutrients intravenously due to malnutrition, and a PICC was ordered on 2/11/2025 for this purpose.

Review of a Consultation Note dated 2/11/2025 revealed that Employee A, Registered Nurse, initiated the PICC placement for Patient ID #1. The note indicated that she advanced the guide wire (a thin, flexible wire used to help guide the placement of the catheter) through the needle, "the wire then became stuck" and so she "took the needle off the guide wire guide and pulled the wire" which "appeared to come longer" and she then "pulled the needle and the wire out of the patient's arm ..."

Record review of diagnostic imaging results from 2/11/2025 for Patient ID #1 revealed that there was an 11-millimeter linear foreign body present within the patient's right arm.

Review of Physician progress notes from 2/11/2025 revealed that based on x-rays and ultrasound imaging of the patient's arm, the retained foreign body went through the basilic vein and a "nonocclusive thrombus (blood clot)" was observed. The note indicated that a plan was made for Patient ID #1 to undergo surgical removal of the retained foreign body.

Record review of an Operative Note dated 2/13/2025, revealed that ultrasound imaging confirmed the location of the foreign body in the basilic vein of the "mid right arm." After local analgesia was administered, an incision was made and the vein was dissected. Subsequently, "what appeared to be the tip of the wire protruding from the vein" was removed.

During a surveyor interview on 2/21/2025 at 9:15 AM with Employee B, Registered Nurse, she revealed that she has been placing PICCs for about 15 years and had trained Employee A to do the same. She explained that on 2/11/2025, Employee A called her and told her that she was concerned about the wire she had pulled from Patient ID #1's arm during her attempt to place the PICC. Employee B then revealed that she went to see the patient and Employee A. Employee B stated that Employee A told her that she had not removed the needle before pulling out the wire and indicated that she advised her to always ensure the needle is removed before pulling the wire to prevent breakage. Employee B stated that when Employee A showed her the wire in question, it looked like the tip had sheared off.

During an additional surveyor interview with Employee B, she revealed that during the PICC placement training she provided Employee A, she reiterated the fact that the needle needs to be removed before the wire is withdrawn to prevent breakage.