HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to implement their policy requiring a physician/licensed individual practitioner's order to access a patient's temporary dialysis central venous catheter (CVC) to obtain a blood sample for routine laboratory (lab) work.

Findings include:

A review of Patient (P)7's medical record revealed that the patient was admitted on 08/11/25 with a diagnosis of plasma cell leukemia and history of hemodialysis treatments. Prior to admission, on 05/09/25, P7 had a tunneled right internal jugular permacath (a type of CVC) placed for hemodialysis treatments. Further review of P7's medical record revealed the following:

Documentation on 08/13/25, 08/17/25, and 08/23/25 indicated that blood samples were obtained by the Registered Nurse (RN) from the dialysis CVC for routine lab work.

An order was placed on 08/11/25 at 7:43 AM for, "... Central Venous Care and Site Assessment (as per policy) ..." There lacked documented evidence of an order specifying the hemodialysis CVC can be utilized to obtain blood for routine lab work.

During an interview on 09/04/25 at 11:10 AM, Staff (S)4 stated that RNs can access a CVC to draw blood samples for ordered labs. S4 stated that a hemodialysis catheter, for example a Shiley, could be accessed by the RN as well if an order was placed.

During an interview on 09/04/25 at 12:51 PM, S1 stated that an order is required to access the central line.

During an interview on 09/04/25 at 1:19 PM, S24 stated that the order for CVC care and maintenance indicated that the RN should refer to the facility policy and procedure on CVC's. S24 explained that it included standard care such as, "flushing, changing the insertion site dressing, and lab draws." S24 stated that lab draws are included in the care and maintenance of a CVC order without it needing to specifically state it can be accessed for hemodialysis patients.

Facility policy titled, "Central Venous Access Device (CVAD) Care & Maintenance in Adult Patients," stated, "... Key Points: ... Registered Nurses who are validated for the care and maintenance of a central venous access device can use a dialysis catheter for IV access and blood draw in emergent situations ONLY when an order is placed in the electronic medical record by the Nephrologist, LIP [licensed independent practitioner], Intensivist or critical care fellow or vascular surgeon. ... Avoid using a hemodialysis catheter for routine blood sampling, blood transfusions, or other infusion medications ..."