HospitalInspections.org

Based on policy review, medical record review, and staff and physician interviews, the hospital's nursing staff failed to supervise and evaluate patient care by: failing to ensure a patient's port-a-cath (central venous line) device was deaccessed prior to discharge and communicate information regarding an accessed port-a-cath device to the receiving facility at the time of transfer for 1 of 2 sampled patients with port-a-cath devices (Patient #3) and failing to reassess a patient's pain and elevated blood pressure per policy for 1 of 7 sampled Emergency Department patients (Patient #9).

The findings include:

1. Review of current hospital policy entitled "Central Venous Line Care" dated 10/2010 revealed, "I. PURPOSE To provide the nurse with guidelines for caring for patients with short or long term venous access devices termination in or near the heart (...Port-a-cath...). II. POLICY A. All central access sites will be maintained in a safe and appropriate manner using optimal aseptic technique....B....If the patient's medical condition does not warrant a central line, the nurse will notify the MD regarding possible discontinuation of the line due to the risk for a catheter-related bloodstream infection increases for every day a device is in use....L. All dressings shall be changed 24 hours after insertion and every seven (7) days....III. DEFINITIONS....2. Long-term devices are...implanted (Port-A-Cath)....The catheter is attached to a port that is located in a subcutaneous pocket....The ports are accessed with special needles....VIII. CRITERIA THAT WARRANTS IMMEDIATE MD NOTIFICATION FOR CONSIDERATION OF DISCONTINUATION OF CENTRAL VENOUS LINES (CVL) 1. Order for discharge or transfer to another facility....XI. PATIENT EDUCATION 1. The patient or primary caregiver should be able to demonstrate and verbalize knowledge regarding care of the CVL including signs and symptoms to report to the doctor. 2. Document on the nursing care plan or teaching guide...."

Review of current hospital policy entitled "DISCHARGE INSTRUCTIONS" dated 10/2011 revealed, "I. POLICY...It is the responsibility of the Registered Nurse to determine the completion of the discharge plan, knowledge, understanding, and ability of the patient and/or significant other to meet continuing patient care needs upon discharge....IV. COMPLETION OF PAPER FORM:...H. Document specific instructions for care to be done at home....1. Includes IV (intravenous) site care....N. Document to whom the nursing instructions were given. (Patient, family member, other)...."

Closed medical record review for Patient #3 revealed a 72 year-old male with a history of stage 4 cancer of the jaw that was admitted on 12/02/2011 from a skilled nursing facility (SNF) with seizure, delirium secondary to seizure, aspiration pneumonia, and sepsis secondary to aspiration pneumonia. Review of the physician's admission history and physical documentation on 12/02/2011 at 1730 revealed, "...SURGICAL HISTORY:...Port (Port-a-cath) placement, unknown date...." Review of a physician's order dated 12/02/2011 at 2058 revealed, "IV (intravenous) Team to access Port-a-cath." Record review revealed a member of the IV Team accessed the Port-a-cath on 12/02/2011 at 2202. Review of the IV Team's notes on 12/02/2011 at 2202 revealed, "Central Line 1 Activity Type: Assess, Flush, Obtain access. Access Type: 20 g(auge) 1" (inch) Huber (needle....Pressure injection needle....Central Line Site: Subclavian vein. Laterality: Right....Central IV Dressing/Activity: Dry, Intact, Biopatch, Labeled. Central Line Site #1 Lumen #1 Color: White. Central Line Site #1 Lumen #1: Capped/adapted...." Record review revealed documentation IV Team staff assessed the accessed Port-a-cath every day. Review of IV Team documentation by RN #1 on 12/09/2012 at 0813 revealed, "Central Line 1....Access Type: 20 g 1" Huber...Port-a-cath, Pressure injection needle....deaccessed and reaccessed per protocol with 20G 1 in(ch) power Huber (needle)....Central IV Site/Line Care: Flushed. Central IV Dressing/Activity: Changed, Biopatch, Transparent....IPOC (Interdisciplinary Plan of Care) Infection Infection: High risk. Infection Interventions: Assess for S/S (signs and symptoms) of Infection....Infection Problems: Invasive lines/cannulations..." Review of Physician #1's Discharge Orders dated 12/09/2011 at 1211 revealed, "Discharge Date: 12/9/11....Transfer to SNF (name of same SNF patient was admitted from)...." Review of the Discharge Orders revealed no mention of the patient's accessed Port-a-cath. Review of the list of medications to be continued at the SNF revealed no intravenous medications were ordered to be given. Review of RN #2's notes on 12/09/2011 at 1500 revealed, "Dt/Tm (Date/Time) Pt Discharged from Unit/Facility: 12/9/2011 14:45...Discharge Note: Pt (Patient) dressed. Discharge packet given to (company name) transporter. Pt. left unit in gerichair. Alert and oriented to himself, as before, in no distress." Record review revealed no documentation the patient's Port-a-cath was deaccessed (needle removed) prior to discharge. Further record review revealed no documentation nursing staff at the hospital reported information regarding the patient's accessed port-a-cath device to staff at the receiving SNF at the time of discharge.

Further closed medical record review for Patient #3 revealed the patient was readmitted to the hospital on 12/20/2011 at 1705 (11 days after discharge to SNF with accessed Port-a-cath). Review of Physician #1's admission History and Physical dated 12/20/2011 at 2045 revealed, "...presents today because he developed a fever at the skilled nursing facility where he lives. They performed a chest x-ray which reportedly showed worsening pneumonia....He was brought to the emergency department where his blood pressure was found to be 74/47, and he was hypoxemic....At the time we saw him, his oxygen saturations were normal, but his blood pressure was very low. It got down to as low as 31/23....He has not been coughing to the daughter's knowledge....PHYSICAL EXAMINATION:...GENERAL: The patient has his eyes open, but barely responds to sternal rub and does not respond to any questions....DATA:...Blood cultures were drawn in the ER....PLAN: The most likely explanation for this is sepsis secondary to either pneumonia or urinary tract infection....Disposition: The daughter, (name), has been informed that he has gotten very sick. She is here at his side and understands the situation...." Review of the IV Team's notes on 12/21/2011 at 1810 revealed, "Central Line 1 Activity Type: Assess, Flush....Access Type: Port-a-cath, Other:...dressing 12/9. Daughter refuses to allow port a cath to be deaccessed and reaccessed until MD sees current dressing. (Name), RN contacted MD and states will be there in 45 minutes - 1 hour....states will page when MD has seen. Central Line Site: Subclavian vein. Laterality: Right....Central IV Dressing/Activity: Dry, Loose...." Review of a physician's progress note dated 12/21/2011 at 1800 revealed, "Spoke w/daughter. Agree that Port date says 12/9. Needle apparently left in since then. Possible infection source. Being treated appropriately per cultures." Review of the IV Team's notes on 12/21/2011 at 2005 revealed, "Central Line 1 Activity Type: Assess, Remove access (Comment: removed access...." Record review revealed the first documentation the patient's Port-a-cath site was accessed was on 12/21/2011 at 1810, when IV Team staff assessed the site (1 day after the patient was readmitted). Record review revealed the patient expired on 12/23/2011 at 2110. Review of the physician's Discharge (Death) Summary dated 12/23/2011 at 2140 revealed, "...presented to the emergency department on 12/20/2011 secondary to fever and hypotension with concern for sepsis....Workup showed possible sources including pneumonia, and blood cultures were drawn which did subsequently grow Staphylococcus aureus. The patient continued to decline....His family decided that they did not want to pursue any further aggressive measures...."

Interview on 05/16/2012 at 1615 with RN #1 revealed the nurse had been on the IV Team for 5 years. Interview revealed a Port-a-cath is a central IV access device in which the port is located under the skin. Interview revealed when a physician orders to access a port, a Huber needle is placed into the port to give access to the central venous system. Interview revealed when a port is accessed, a clear occlusive dressing is placed over the site. Interview revealed the dressing must be changed at least every 7 days in order to prevent infection at the site. Interview revealed a physician's order is required to deaccess a port or to discharge a patient with a port accessed. Interview revealed patients are usually discharged with an accessed port only if central venous access is required at discharge and follow-up care of the accessed port is arranged with after-care staff.

Interview on 05/17/2012 at 0915 with RN #2 revealed the nurse was Patient #3's primary nurse on the Neurosciences Unit on 12/09/2011 during the day shift. Interview revealed, "The discharge orders were written and the discharge was typed up while I was at lunch....I don't remember paying mind to that (the patient's port being accessed at time of discharge)....I did not call report to the facility. I think the charge nurse did. Transport came shortly after I returned from my break to pick the patient up....I don't recall if the patient was in IV meds at the time of discharge that would require the port to be accessed....My thinking at the time was that if the physician wanted it (the port access) to be discontinued then he would have ordered it." Further interview revealed "not too long after" the patient returned to the hospital (on 12/20/2011), the interim nurse manager talked with the nurse about the event in which the patient was discharged on 12/09/2011 with an accessed Port-a-cath without orders for the same. Interview revealed the nurse had been unaware of the policy requiring a physician's order to discharge a patient with an accessed port until the interim nurse manager talked to her.

Interview on 05/17/2012 at 1045 with RN #3 revealed the nurse was the Charge Nurse on the Neurosciences Unit on 12/09/2011 during the day shift. Interview revealed a Port-a-cath should be deaccessed prior to discharge. Interview revealed a physician's order was required to leave an access in at discharge or to deaccess the port. Interview revealed the nurse did not recall Patient #3. Interview revealed, "With nursing homes (SNFs) we normally don't call report." Interview revealed a packet of information is sent with each patient to the SNF. Interview revealed the packet includes lab results, Discharge Summary, History and Physical, 72 hour Medication Administration Record, FL2 (nursing home placement tool), and discharge instructions.

Interview on 05/17/2012 at 0940 with the Manager of Clinical Education revealed the medical record was reviewed concurrently with the Manager during the interview. Interview revealed the Manager confirmed there was no available documentation of a physician's order to discharge the patient on 12/09/2011 with an accessed Port-a-cath. Interview confirmed there was no available documentation of discharge instructions related to the accessed port. Interview confirmed there was no available documentation nursing staff communicated report to SNF staff about the patient's discharge condition, including the accessed port. Further interview confirmed neither the Discharge Summary, History and Physical, 72 hour Medication Administration Record, FL2, or discharge instructions for the patient's 12/09/2011 discharge to the SNF contained information or instructions regarding the patient's accessed Port-a-cath.



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2. Review of the hospital's "Vital Signs" policy revised September 2011 revealed "I. Policy: All patients presenting to the Emergency Care Center will have vital signs documented according to the following criteria. II. Procedure: A. Adults and children over the age of five: ...4. Blood Pressure... C. Vital signs will be recorded every 4 (four) hours from the time of arrival on every patient if they remain in the ED or more frequently if condition or intervention indicates. Abnormal vital signs are to be rechecked within 1 hour or more frequently, if indicated.... E. Vital signs will be reassessed at each discharge, admission, and transfer.... F. Abnormal vital signs: 1. Repeat the vital signs for accuracy. 2. Notify the physician if repeat vital signs are abnormal. 3. Extreme blood pressures should be repeated using a manual cuff and stethoscope. G. The following are vital signs within accepted discharge criteria: 3. Blood Pressure Age 18 years and older = 85-180/50-110...."

Review of the hospital's "Pain Assessment and Management" policy reviewed/revised April 2010 revealed "... Patients will be assessed on admission for presence, absence, and history of pain using an age appropriate objective rating scale (i.e. Wong Baker or numerical rating scale) and ongoing reassessments at regular and periodic intervals.... Pain intensity is evaluated after each pain management intervention once a sufficient time has elapsed for treatment to reach peak effect...."

Closed medical record review of Patient #9 revealed a 50 year-old male that presented to the emergency department (ED) on 09/26/2011 at 1420 with a chief complaint of back pain. Review of nursing triage notes revealed the patient's blood pressure (BP) was 180/100 with a pain level of 7 (scale of 1-10 with 10 the worst pain) at 1625. Review of the record revealed the patient received medication for pain at 1658. Review revealed the patient was discharged home at 1800. Further record review revealed no evidence the patient's blood pressure or pain level was reassessed prior to discharge or after the pain medication was administered.

Interview on 05/16/2012 at 1350 with an emergency department administrative nursing staff member confirmed there was no documentation that the patient's blood pressure or level of pain was reassessed after an intervention and prior to discharge. Interview revealed nursing staff failed to follow the hospital policy.

Further review revealed Patient #9 returned to the ED on 11/02/2011 at 0841 with a complaint of headache, vomiting and back pain. Review of nursing triage notes revealed the patient's blood pressure (BP) was 181/102 at 0856. Review revealed the patient's blood pressure was 170/102 at 1404 (5 hours and 23 minutes since prior BP check). Review revealed the patient was discharged home at 1505. Further record review revealed no evidence the patient's blood pressure was reassessed at the time of discharge.

Interview on 05/16/2012 at 1335 with an emergency department administrative nursing staff member confirmed there was no documentation that the patient's blood pressure was reassessed every four hours or at the time of discharge. The staff member stated that "usually with a BP that high, the patient is placed on automatic BP checks every 15 minutes." Interview revealed nursing staff failed to follow the hospital policy.

Further review revealed Patient #9 returned to the ED on 04/25/2011 at 1303 with a complaint of body aches and possible stroke. Review of nursing triage notes revealed the patient's blood pressure (BP) was 156/112 at 1310. Review revealed the patient's blood pressure was 170/97 at 1500 (1 hour and 50 minutes since prior BP check) and 168/103 at 1843 (3 hours and 43 minutes). Review revealed the patient was discharged home at 2034. Further record review revealed no evidence the patient's blood pressure was reassessed at the time of discharge.

Interview on 05/16/2012 at 1340 with an emergency department administrative nursing staff member
revealed the patient's blood pressure of 156/112 was outside the normal parameters identified in the policy and should have been monitored more frequently. Interview confirmed there was no reassessment of the blood pressure at the time of discharge. Interview revealed nursing staff failed to follow the hospital policy.

NC00077425, NC00077752, and NC00077496