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Based on record review and staff interview, it has been determined that the hospital governing body has failed to ensure that nursing care was provided in accordance with hospital policy for 1 of 2 patients (patient ID #1) with orders to discharge home with a Peripherally Inserted Central Catheter (PICC) in place. The hospital governing body has also failed to ensure that nursing care was provided in accordance with the hospital policy for Removal of an Intravenous (IV) Catheter.

(PICC is usually inserted in a smaller vein, and terminates in a larger vein in the chest near the heart. IV catheter is placed into a peripheral vein. Both PICC and IV catheter are placed for intravenous therapy such as medications or fluids).

Findings are as follows:

I. Review of the "Insertion and Removal of the Central Venous Catheter and Management of the Occluded Central Venous Catheter" policy, revised on September, 2017, states in part,

"POLICY

The Department of Nursing will provide standard procedures and guidelines to make placement and removal of central venous catheters efficient, effective, and safe...

SCOPE OF APPLICABILITY

This policy applies to ordering provider, registered nurse (RN), and the student nurse (SN) under the guidance of the instructor...

RESPONSIBILITY

...It is the responsibility of the RN, or SN under the guidance of the instructor to:...
Discontinue/remove central lines when ordered..."

II. Review of the "Insertion, Maintenance, and Removal of an Intravenous Catheter" policy, revised on August, 2016, states in part,

"SCOPE OF APPLICABILITY

The policy applies to ordering providers, registered nurse (RN), Student Nurse Associate Professional (SNAPs) in the EMERGENCY Department, student nurses (SN) under the guidance of an instructor,...

RESPONSIBILITY

It is the responsibility of RNs, SNP, and SN, under the guidance of an instructor to...
discontinue the IV catheter ..."

Record review revealed patient ID #1 presented on 9/28/2018 with osteomyelitis (infection of the bone) for scheduled PICC insertion and surgery on his/her left foot. The plan was to discharge home on the same day with the PICC in place for continued antibiotic therapy. The record indicates the PICC "was accidentally pulled out by staff". This resulted in the patient being admitted, overnight, for observation as well as the placement of a new PICC.

During an interview on 10/25/2018 at 9:30 AM, the Site Risk Manager revealed there was no order to remove the PICC and that the PICC was removed by a nursing assistant (NA). The Site Risk Manager also revealed that it is their practice that NA (s) working in the post-anesthesia care unit (PACU) and Emergency Department (ED) can remove peripheral IV catheters.

During an interview on 10/26/2018 at 1:10 PM, the Vice President of Patient Care Services and Chief Nursing Officer who is a member of the hospital governing body, revealed that she and other nursing leaders were aware of this practice. She agreed that this practice is not in keeping with the hospital policy and that the governing body had not addressed the practice of delegating the removal of IV Catheters to NA (s).

(Refer to A 385, A 395 and A 397)

Based on record review and staff interviews, it has been determined that the hospital has failed to meet the Condition of Participation relative to Nursing Services for patient ID #1 who had a Peripherally Inserted Central Catheter (PICC) and/or patients who had Peripheral Intravenous (IV) Catheters. The severity of this failure was determined to constitute Immediate Jeopardy.

Findings are as follows:

1. The facility has failed to provide nursing care for in accordance with the hospital policy for Insertion and Removal of the PICC for patient ID #1. The facility has also failed to provide nursing care for each patient in accordance to the hospital policy for Insertion, Maintenance, and Removal of a peripheral IV Catheter (refer to A 395).

2. The facility has failed to assign the nursing care for each patient to other nursing personnel in accordance with the patient's needs and specialized qualification and competence of the nursing staff available (refer to A 397).

Based on record review and staff interviews, it has been determined that the hospital has failed to provide nursing care for each patient in accordance with hospital policy for 1 of 2 patients (patient ID #1) who had a Peripherally Inserted Central Catheter (PICC). The hospital has also failed to provide nursing care for each patient in accordance with the hospital policy relative to Insertion, Maintenance, and removal of a peripheral Intravenous (IV) Catheter.

Findings are as follows:

I. Review of the "Insertion and Removal of the Central Venous Catheter and Management of the Occluded Central Venous Catheter" policy, revised on September, 2017, states in part,

"POLICY

The Department of Nursing will provide standard procedures and guidelines to make placement and removal of central venous catheters efficient, effective, and safe...

SCOPE OF APPLICABILITY

This policy applies to ordering provider, registered nurse (RN), and the student nurse (SN) under the guidance of the instructor...

RESPONSIBILITY

...It is the responsibility of the RN, or SN under the guidance of the instructor to:...
Discontinue/remove central lines when ordered..."

Record review revealed patient ID #1 has a history of osteomyelitis (infection of the bone). The patient had a PICC insertion and surgery on his/her left foot on 9/28/2018. The plan was the patient to go home that day with the PICC in place for IV antibiotic therapy. The record indicates the PICC "was accidentally pulled out by staff". This resulted in the patient being admitted overnight for observation as well as the placement of a new PICC.

During an interview on 10/25/2018 at 9:30 AM, the Site Risk Manager revealed there was no order to remove the PICC and that patient's ID #1's PICC was removed by staff A, a nursing assistant (NA).

During an interview on 10/26/2018 at 11:05 AM, staff A revealed she removed the PICC because she though it was a peripheral IV catheter. She further revealed that during the procedure of removing the catheter she noted that it was not a peripheral IV catheter. She then informed the patient's nurse (staff J) of the incident.

II. Review of the "Insertion, Maintenance, and Removal of an Intravenous Catheter" policy, revised on August, 2016, states in part,

"SCOPE OF APPLICABILITY

The policy applies to ordering providers, registered nurse (RN), Student Nurse Associate Professional (SNAPs) in the EMERGENCY Department, student nurses (SN) under the guidance of an instructor,...

RESPONSIBILITY

It is the responsibility of RNs, SNP, and SN, under the guidance of an instructor to...
discontinue the IV catheter ..."

During an interview on 10/25/2018 at 9:30 AM, the Site Risk Manager revealed it is their practice that NA (s) who works in a post-anesthesia care unit (PACU) and Emergency Department (ED) can remove peripheral IV catheters when patients are ready to be discharged.

During an interview on 10/25/2018 at 2:00 PM, the ED Nurse Director revealed RN usually removes the IV catheter, however, this task "can be delegated" to a NA "when the nurse is busy".

During an interview on 10/25/2018 at 2:10 PM, the ED nurse (staff R) revealed she has been working in the ED for approximately 14 years. She revealed NA (s) can remove peripheral IV catheters. She has seen NA removing peripheral IV catheters and she has asked a NA (s) to perform this task.

When questioned on 10/26/2018 at 10:45 AM, a PACU nurse (staff J) revealed she has asked NA (s) to remove peripheral IV catheters when patients were ready to be discharged.

During an interview on 10/26/2018 at 11:05 AM, a NA (staff A) revealed she has been working in PACU for the last few months and has removed peripheral IV catheters when patients were ready to be discharged.

During an interview on 10/26/2018 at 11:30 AM, a NA (staff K) who has been working in the PACU at approximately 15 years, revealed he has removed peripheral IV catheters when asked by nurses.

During an interview on 10/26/2018 at 11:40 AM, a NA (staff L) who has been working in PACU for approximately 3 years, revealed she has removed peripheral IV catheters.

The surveyors interviewed the Director of PACU on 10/26/2018 at 11:50 AM, he revealed nurses usually take out the IV but "there are times, NA takes them out" when asked by nurses.

During an interview on 10/29/2018 at approximately 2:00 PM, the Site Risk Manager acknowledge that the hospital policies for Removal of the Central Venous Catheter and peripheral IV catheter were not followed.

(refer to A 397)

Based on record review and staff interview, it has been determined that the facility has failed to assign the nursing care for each patient to other nursing personnel in accordance with the patient's needs and specialized qualification and competence of the nursing staff available.

Findings are as follows:

Record review revealed patient ID #1 has a history of osteomyelitis (infection of the bone). The patient had a Peripherally Inserted Central Catheter (PICC) insertion and surgery on his/her left foot on 9/28/2018. The plan was the patient to go home that day with the PICC in place for intravenous (IV) antibiotic therapy. The record indicates the PICC "was accidentally pulled out by staff". This resulted in the patient being admitted overnight for observation as well as the placement of a new PICC.

During an interview on 10/25/2018 at 9:30 AM, the Site Risk Manager revealed that the PICC was removed by staff A, a nursing assistant (NA). The Site Risk Manager also revealed that it is their practice that NA (s) who works in a post-anesthesia care unit (PACU) and Emergency Department (ED) can remove peripheral IV catheter when patients are ready to be discharged.

During an interview on 10/26/2018 at 11:05 AM, staff A revealed that she has been working in PACU for the last few months and has removed peripheral IV catheters when patients were ready to be discharged. Staff A revealed that she removed patient ID #1's PICC because she though it was a peripheral IV catheter.

During an interview on 10/26/2018 at 11:30 AM, a NA (staff K) who has been working in the PACU for approximately 15 years, revealed he has removed peripheral IV catheters when asked by nurses.

During an interview on 10/26/2018 at 11:40 AM, a NA (staff L) who has been working in the PACU for approximately 3 years, revealed she has removed peripheral IV catheters.

During an interview on 10/29/2018 at approximately 2:00 PM, the Site Risk Manager was unable to provide evidence that the above NA (s) have specialized qualifications and documentation of competencies to remove peripheral IV catheters.

(refer to A 395)