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Based on records reviewed and interviews the Hospital failed for one patient (Patient #1) of ten patients sampled to implement and monitor corrective actions after Patient #1's complaint of pain for 12 days due to a mal-positioned Peripherally Inserted Central Catheter (PICC).

Findings included:

The Quality Assurance and Performance Improvement Plan, dated 6/26/19, indicated the Medical Staff Executive Committee was responsible for performance improvement services provided by members of the Medical Staff. The Quality Assurance and Performance Improvement Plan indicated performance improvement activities that track adverse patient events, analyze their causes and implement preventative actions and mechanisms that include feedback and learning throughout the Hospital were supported and facilitated by the Patient Safety and Quality Program. The Quality Assurance and Performance Improvement Plan indicated a purpose of the Patient Safety and Quality Program was to reduce preventable patient safety events.

The Physician Admission Note, dated 1/23/19, indicated Patient #1 presented to the Hospital with complaints of upper respiratory infection (URI) symptoms and fever.

The Physician Inpatient Note, dated 2/20/19, indicated Patient #1 had a bronchoscopy (a test to examine the airways) procedure on 2/7/19. The Physician Inpatient Note indicated that due to reports of chest pain with line flushing a line study was obtained and showed a mal-positioned (not in the intended blood vessel) PICC and that the mal-positioned PICC was pulled (discontinued) on 2/19/19.

The Surveyor interviewed Patient Safety Manager #1 at 10:15 A.M. on 6/13/19. The Patient Safety Manager #1 said Patient #1 had the PICC placed while in the operating room (for the bronchoscopy procedure) on 2/7/19. The Patient Safety Manager #1 said two chest x-rays, one chest x-ray on 2/9/19 and the second chest x-ray on 2/14/19, confirmed by the Radiology Department and the Physician Team that the PICC was placed correctly. Patient Safety Manager #1 said the Hospital investigated Patient #1's mal-positioned PICC and determined the cause was physicians "anchoring" on the chest x-ray interpretations that the PICC was in good position. The Patient Safety Manager #1 said that nursing staff on Patient #1's Patient Care Unit implemented nursing corrective actions regarding communication and activation of the Hospital's Chain of Command Policy (line of authority and responsibility along which patient concerns are communicated within a Nursing Department). Patient Safety Manager #1 said the Hospital cared for patients with PICCs on every Patient Care Unit.

The Surveyor interviewed the Associate Chief Nursing Officer and Nurse Manager #1 at 12:45 P.M. on 6/13/19. The Associate Chief Nursing Officer and Nurse Manager #1 said nursing corrective actions (regarding the adverse patient event of Patient #1's mal-positioned PICC) were not implemented on every Patient Care Unit (at the time of the Survey).

The Hospital provided no documentation to indicate implementation of nursing corrective actions after Patient #1's mal-positioned PICC.

The Surveyor interviewed the Chief of Radiology at 1:20 P.M. on 6/13/19. The Chief of Radiology said the Radiology Department misinterpreted Patient #1's lateral (a chest x-ray taken from the side of the patient) chest x-ray that showed the mal-positioned PICC. The Chief of Radiology said an anesthesiologist placed Patient #1's PICC in the Operating Room. The Chief of Radiology said that the corrective action included reinforcement to the Radiology Department on anchoring.

The Hospital provided no documentation that the corrective action regarding anchoring was monitored. The Hospital provided no documentation that lateral chest X-rays were monitored for correct PICC line placement.