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A. Based on document review and staff interview it was determined nursing supervision failed to ensure all nurses consistently and accurately evaluate and identify all vascular access devices which are used for patients who have implantable ports. This deficient practice was discovered in one (1) of four (4) patient records reviewed for patients who had a vascular access device that had been used to access the implanted port. When nursing staff does not accurately identify access devices used with implantable ports, this can lead to lines which are incorrectly managed, resulting in negative patient outcomes.


Findings include:


Patient #1 on the identifier list was a seventy-eight (78) year old male who presented to the Emergency Department (ED) by ambulance on 5/8/15 at 4:10 p.m. with complaints of fever. On 5/8/15 at 4:42 p.m. Registered Nurse (RN) #3 documented accessing the patient's Medi-Port which flushed easily. At 4:42 p.m. a normal saline intravenous infusion (IV) was started at 75 milliliters (ml) an hour. The patient was admitted to an observation bed on the medical surgical floor at 10:40 p.m.


Further review of the Patient #1's record revealed nursing entries relative to IV therapy. RN #1 admitted the patient to observation on 5/8/15 at 11:30 p.m. and documented in an admitting nursing assessment the patient had a double lumen power port in the right subclavicular area and the size was an eighteen (18) gauge. On 5/9/15 at 7:35 p.m. RN #1 recorded the patient had a vascular access device which was a double lumen Hickman catheter in the right subclavicular area and the size was an eighteen (18) gauge.


RN #2 recorded in a general nursing assessment on 5/10/15 at 8:33 a.m. the patient had a double lumen vascular access device located at the right subclavicular area and the size was an eighteen (18) gauge. At 9:59 a.m. on 5/10/15 RN #2 documented: "IV catheter removed whole and intact. Gauze and pressure applied to site."


RN #3 was interviewed by phone on 6/23/15 at 1:00 p.m. He said he remembered this patient and cared for him in the ED. He explained the patient had an implanted port which he accessed with a Huber needle. He admitted he did not document the type of device that he used to access the port or the location of the port.


RN #1 was interviewed on 6/23/15 at 7:45 a.m. She stated she remembered Patient #1. She admitted the patient to the ED and completed the admitting physical assessment. She explained the patient had a power port peripherally inserted central catheter (PICC) located in the right subclavian area and a double lumen catheter. RN #2 was questioned about the entry she made in the general nursing assessment on 5/9/15 at 7:35 p.m. where she had changed the name of the vascular access device to a Hickman. RN #1 explained the catheter was a double lumen Hickman catheter which is a catheter that is located on the outside and is not indwelling.


RN #2 was interviewed on 6/23/15 at 1:40 p.m. The nurse said she really did not remember much about Patient #1. RN #2 was questioned about what type of vascular access device she removed from Patient #1 on 5/10/15 at discharge. RN #2 reviewed her notes and said since she documented she removed a catheter, it must have been a peripheral IV access. RN #2 reviewed all of her documentation, including the section where she identified the vascular access device as a double lumen at the right subclavian and power port, and said if it was a power port she would have recorded flushing and deaccessing the port. RN #2 could not explain the discrepancy between documenting the removal of a catheter, which would not be used in deaccessing and flushing a port.


A request made on 6/24/15 at 2:30 p.m. for the Huber needles used to access an implanted port revealed the hospital has two (2) access devices stocked and used for accessing implanted ports. The first access device was a Power Lock manufactured by Bard Corporation. The Power Lock device has a single line with one (1) luer activated injection site that is attached to a needle which is inserted into the patient's port. The second device was a Gripper Plus manufactured by Smith's Medical. This device has a non-coring safety needle with a single line that has two (2) luer activated needle injection sites.


The National Institute of Health's patient education for Hickman catheters provided the following description of the Hickman catheter: "The catheter is a thin, long tube made of flexible silicone rubber. It is surgically inserted into one of the main blood vessels leading to the heart. The other end of the catheter exits though the skin. Depending on therapy needs, the catheter may have either a single (1), double (2), or triple (3) lumen (channel) at the tip."


B. Based on document review and staff interview it was determined nursing supervision failed to ensure that all nursing staff follow physician orders for insertion of peripheral IV accesses or notify the physician of the need to discontinue or change the order. This deficient practice was discovered in three (3) out of four (4) patients admitted with implanted ports (Patient #1, Patient #2 and Patient #3). When nurses do not follow physician orders as directed, it can result in patient injury or adverse outcomes.

Findings include:

1. Review of the Patient #1's medical record revealed he was a seventy-eight (78) year old male who was admitted to an observation bed on 5/8/15 with a diagnosis of fever in an immunocompromised patient. The record contained admission orders dated 5/8/15 at 10:24 p.m. for peripheral intravenous (IV) insertion and maintenance. The record lacked documentation the IV was started.

Interview with RN #1 on 6/23/15 at 7:45 a.m. revealed she admitted the patient and acknowledged the IV order. On 5/8/15 at 8:17 p.m. RN #1 was questioned about the physician's order for a peripheral IV insertion and management. She stated she did not start a peripheral IV due to the patient having a peripherally inserted central catheter (PICC) line that could not be used. RN #1 admitted she did not call the physician to cancel the order because the physicians use order sets which include items that are not used or followed.

2. Review of Patient #3's medical record revealed the patient was a seventy-two (72) year old who was admitted on 6/19/15 with a diagnosis of partial small bowel obstruction. Admission orders dated 6/19/15 at 9:19 p.m. included an order for a peripheral IV insertion and management. The medical record lacked documentation that the peripheral IV was started.

3. Review of the medical record for Patient #4 revealed the patient was a seventy-two (72) year old male who was admitted on 3/18/15 with a diagnosis of bowel obstruction. Admission orders dated 3/18/15 at 11:14 p.m. included an order for a peripheral IV insertion and management. The medical record lacked documentation the peripheral IV was started.

Patient #3 and Patient #4's medical records were reviewed with the Quality Coordinator on 6/24/15 at 11:20 a.m. She agreed these records did not have documentation that a peripheral IV had been started and the physician had not been called to change or discontinue the order.

Based on document review and staff interview it was determined nursing failed to ensure all nurses assigned to patients with implanted ports have training and have demonstrated competency in the identification and managing of vascular access devices used for implanted ports. This deficient practice was found for three (3) out of three (3) RNs (RN #1, RN #2 and RN #3) who cared for Patient #1. Nurses not being fully trained or competent in managing access devices used for implanted ports can result in possible medical errors including adverse patient outcomes.

Findings include:

Review of the Patient #1's medical record revealed he was a seventy-eight (78) year old male who was admitted from the hospital ED to an observation bed on 5/8/15. RN #3 documented in an ED note on 5/8/15 at 4:42 p.m. she accessed the patient's Medi-Port which flushed easily. She also noted she initiated an IV saline infusion. Additional nursing entries relative to the patient's intravenous access device were made by RN #1 and RN #2 in the observation record.

Review of training and competency records for RN #1, RN #2 and RN #3 revealed all records lacked evidence of training and competency in the identification and managing of vascular access devices used for implanted ports.

The Director of Quality reviewed the above training and competency records on 6/24/15 at 8:30 a.m. and agreed these records did not contain any training or competency on the identification and management of vascular access devices used for implanted ports.