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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff checked for patient allergies prior to placement of peripherally inserted central catheters (PICC) lines. (A0392)

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff checked for patient allergies prior to placement of peripherally inserted central catheters (PICC) lines. This affected one patient (Patient #3) out of ten reviewed. The facility census was 353 .

Findings include:

Review of the medical record of Patient #3 revealed the patient presented to the facility's emergency Department (ED) on 12/03/24 at 3:25 PM with one to two days of left eye pain and blurry vision. The patient stated her eye was nearly swollen shut and she presented to the ED due to concern for infection. The patient was prescribed the antibiotic erythromycin, advised to follow-up with an ophthalmologist, and discharged home. According to a hospitalist's History and Physical the patient saw an ophthalmologist who wasn't able to determine optic nerve etiology. The patient saw a second ophthalmologist and there was concern for possible optic neuritis with suspicion for infection versus multiple sclerosis. Patient #3 presented to the ED again on 12/04/24, was admitted, and neurology was consulted. A neurology note on 12/05/24 stated results of an magnetic resonance imaging scan were consistent with bilateral optic neuritis. Allergies listed in the record included Lidocaine which causes an anaphylactic reaction.

Review of the physician order dated 12/11/24 revealed an order for a double lumen PICC line to be placed for inpatient vascular access.

A note on 12/11/24 at 4:56 PM, composed by an intravenous (IV) therapy registered nurse (RN), stated the nurse arrived to the patient's bedside to place a PICC line. A pre-procedure and timeout were performed with the bedside nurse. A consent was confirmed, vital signs were stable, and no contraindications were noted. The note further stated laboratory tests, allergies, medications, and code status were reviewed. The note stated Lidocaine was administered. The procedure note documented the patient reported her tongue was swelling a short time after the Lidocaine was administered. A rapid response was called due to the possibility of an anaphylactic reaction.

The rapid response team note stated the team was called to the patient's bedside due to the patient's tongue swelling after Lidocaine, a medication she was allergic to, was administered. Upon arrival of the rapid response team the patient was noted to be alert and oriented, however she was complaining of tongue swelling. Benadryl 25 milligram (mg), Solumedrol 125 mg, and Epinephrine 1 mg were administered via IV and the tongue-swelling improved.

Review of the Discharge Summary revealed the PICC nurse was able to complete placement of the PICC line. The PICC line was successfully used for administration of medication. The patient was discharged on 12/17/24. The PICC line was discontinued prior to discharge.

Review of the facility policy titled "Peripherally Inserted Central Insertion per Vascular Access Services," last reviewed in 08/2024, revealed a peripherally inserted central catheter is a central venous catheter inserted percutaneously through the veins of the upper extremity. The staff nurses are instructed, in step two of the procedure, to verify allergies prior to pre-procedure.

Interview on on 04/10/25 at 2:00 PM, Staff C confirmed this finding.