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Based on hospital policy review, medical record review, physician interview, staff interview, and staff personnel file review, the hospital failed to provide adequate supervision by a registered nurse over the care of a hemodialysis patient's dialysis access as evidenced by hospital patient care staff accessing the patient's dialysis access for non-emergency use and without a provider's order in following the hospital's policy and procedure for hemodialysis catheter access for 1 of 1 sampled hemodialysis patients having their hemodialysis catheter accessed by the hospital's nursing staff (Patient #5).

Findings include:

Review on 10/21/2015 of the hospital's policy and procedure "Hemodialysis and Pheresis Catheter (Vas-Cath and Perm-Cath) Care" (Effective Date: 06/03/2015) revealed "Definitions: Vascular access is needed for hemodialysis and pheresis procedures. A hemodialysis/pheresis catheter is a large gauge double-lumen central venous catheter." The policy further revealed "Tunneled cuffed catheter (e.g., perm cath) intended for longer use. Tunneled catheters are inserted in a central vein (subclavian, internal jugular, or femoral veins) and subcutaneously tunneled to an exit site. The catheters are locked with a high dose of heparin to prevent catheter occlusion." Further policy review revealed "Personnel: In approved areas only, RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) may, after demonstrating competency, flush, administer medications through, attach to a pressurized flush system, dress or deaccess (instilling heparin or attaching pressure bag). Approved Areas: Dialysis, Vascular Interventional Radiology, Outpatient Pheresis Clinic, Emergency Department, Adult Bone Marrow Transplant, Children's Health Center, Vascular Access Services Team. Policy Statement: Purpose: To outline the care of the patient with a hemodialysis/pheresis catheter. Content: A. Accessing, Emergency Use Only-Bedside RN. Caution: Important Points for Pheresis and Hemodialysis Catheters
· DO NOT use catheters with NO BLOOD RETURN.
· DO NOT flush catheter lumen. Heparin must be withdrawn prior to use.
· Catheters need to have the heparin withdrawn followed by 5 ml (Milliliters) saline flush and reinstallation of high dose heparin according to the lumen fill volume (as stamped on catheter) weekly if not in use for pheresis.
· Provider order from fellow is needed prior to accessing these catheters.

1. Routine access of hemodialysis/pheresis catheters is discouraged. If non-emergency access is determined to be necessary, notify the following prior to accessing the catheter.
2. Hemodialysis catheters- Notify Renal Fellow (Pager #_____)
B. *Accessing Procedure:
10. Notify hemodialysis or pheresis nurse as soon as possible so catheter can be flushed with appropriate heparin flush solution to prevent catheter occlusion." Review of the policy's documentation section also revealed "Documentation: Reportable Conditions...1. To provider: c. Open or missing needless caps (indicating contamination). 2. To hemodialysis unit/nurse: d. Catheter accessed for any purpose other than dialysis or pheresis."

A closed medical record review on 10/20/2015 for patient #5 revealed the 53 year-old female was admitted to the hospital on 10/05/2015 through 10/10/2015. Review revealed the patient was admitted for a scheduled surgical procedure to declot her thrombosed left arm "HERO graft" (Arm Hemodialysis Vascular Access). The patient also was documented as pre-hospitalization having a right femoral area "perm-cath" (Hemodialysis Catheter) placed on 08/05/2015 as a result of her clotted "HERO graft" in order to receive her hemodialysis treatments. Documentation review revealed the patient's surgical procedure on 10/05/2015 to declot the "HERO graft" was cancelled for the patient due to a reported low hemoglobin that resulted in need for blood transfusions. Review revealed the hospital's anesthesiologist (Physician #1) on 10/05/2015 during the scheduled procedure for the declot of the patient's graft documented on the anesthesia note that the hospital's preoperative staff was unable to access the patient's veins peripherally and the patient's right central line (perm-cath) would be accessed in surgery. Documentation revealed the pre-operative nursing staff accessed the patient's hemodialysis catheter (perm-cath) at a TKO (To keep Open) rate. The patient was documented as transferred for admission from the hospital's pre-operative area to the hospital's surgical unit with her perm-cath connected to "Lactate Ringers" solution at TKO. Documentation for the patient revealed that she was ordered to receive transfusion of RBCs (Red Blood Cells) on 10/05/2015 at 1633 that was administered by the unit's registered nurse (RN #1) on 10/05/2015 at 2015 for the 1st unit and 2145 for the 2nd unit. Documentation revealed the 2nd unit of RBCs was discontinued after transfusion on 10/05/2015 at 2331 with no complications documented. Review of the patient's medical record revealed that no provider order was obtained to access the patient's hemodialysis catheter (perm-cath) before the blood transfusions nor was the documentation indicating the blood transfusion was an "emergency use." Continued review of the patient #5's medical record revealed documentation on 10/06/2015 at 1534 from RN #2 on the surgical unit indicating "Patient off floor at beginning of shift to dialysis. Dialysis RN called at approximately 0800 reporting that they were unable to start dialysis on the patient due to a contaminated femoral perm-cath. Patient returned to floor. RN (#2) placed order for IV (intravenous) placement due to inability to use contaminated port (Patient's Hemodialysis Catheter)." The documentation review further revealed that the patient's hemodialysis catheter perm-cath was missing a "hub cap" that caused the contamination of the patient's dialysis access and subsequently led to prophylactic administration of IV antibiotics and another surgical procedure on 10/07/2015 for another exchange of perm-cath again in her groin. The review of the patient's medical record failed to reveal a physician or provider order to access the patient's hemodialysis catheter while on the surgical unit. The review of the patient's medical record failed to reveal the hemodialysis unit and nurses were notified to assist in accessing the hemodialysis catheter.

Interview on 10/21/2015 at 0935 with the hospital's pre-operative nursing staff (RN #3) revealed that she did help take care of patient's #5 on 10/05/2015 during her canceled procedure for declot of her "HERO graft." The interview revealed the patient's hemodialysis catheter in her right groin was accessed with "Lactate Ringers" infusing at a KTO rate. The interview also revealed that the patient was transferred up to the surgical unit and report given to the nursing staff on that unit for care of the patient. The interview revealed that no orders were given to use the dialysis access, but it was up to the anesthesiologist.

Interview on 10/21/2015 at 1215 with RN #2 of the surgical unit revealed that at beginning of her shift on 10/06/2015, she received a phone call from the hemodialysis nurse on the hemodialysis unit reference patient #5's dialysis catheter was contaminated. The interview revealed that RN #2 asked the dialysis nurse why and she stated to her that "cap" was off. The interview also revealed that the surgical staff generally does not access dialysis accesses. The interview did revealed that the patient was upset over her dialysis catheter access site contaminated. The interview also revealed that she never heard of any issues related to the patient's cap missing before the dialysis nurse called and informed her of it.

Interview on 10/21/2015 at 1435 with physician (Fellow) #1 (Nephrology) revealed that she was not the attending physician for patient #5 but did document a discharge note. The interview also revealed that the dialysis nurse on 10/06/2015 also informed her of the patients missing cap that day. The interview revealed that a decision was made to replace the perm-cath for the patient along with antibiotics due to risk of contamination. The interview also revealed no knowledge of requirement as in hospital policy and procedure that a provider (fellow) give an order for staff to access a hemodialysis catheter for patients other than in hemodialysis and pheresis. The interview revealed "I am not sure if order is needed or not. It should be based on hospital policy." The interview did revealed that emergency use only was the reason for accessing the hemodialysis catheters and she was not sure if patient #5 had an emergency issue.

An attempted interview on 10/21/2015 at 1517 with RN #1 was done but the staff member was not available for interview according to the hospital's administrative staff.

A personnel file review on 10/21/2015 for RN #1 revealed that the staff had no training or education documented for accessing hemodialysis catheter perm-caths.

In addition, the patient presented to the hospital on 10/05/2015 for a procedure of declotting her left arm hemodialysis access that had caused her to use a placed right femoral hemodialysis catheter perm-cath since 08/05/2015. The patient's procedure was canceled due to low hemoglobin after her hemodialysis access in right femoral area had been accessed in pre-operative unit at a KTO rate. The patient was admitted to hospital and transferred up to the surgical unit with the hemodialysis still accessed with IV fluids at KTO rate. On 10/05/2015 the patient was transfused 2 units of RBCs through her right femoral hemodialysis catheter by the surgical unit's RNs without an obtained provider or physician order as well as failing to contact the hemodialysis unit/nurse to assist with accessing the catheter. The following day on 10/06/2015, the patient went for hemodialysis at the hospital hemodialysis unit and it was not completed due to report by a hemodialysis nurse that the hemodialysis catheter was contaminated due to a missing cap. The patient as a result of having her hemodialysis catheter accessed had to undergo another surgical procedure for exchange of the catheter as well as prophylactic antibiotic administration.


NC00111091