HospitalInspections.org

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Based on document review and staff interview, the facility failed to ensure an incident with an adverse outcome was thoroughly investigated and actions implemented to address identified problems.

Findings include:

Review of Quality Assurance Report for 2019 identified that on 3/15/19, a patient had a Central line catheter placement. Post procedure x-ray noted the Central Line was "most likely in the left Brachiocephalic Vein (a large vein in the neck)." On 3/16/19, the patient developed a stoke and was transferred to another facility for neurological services and care. The receiving facility found that the patient's central line was in the left Carotid Artery (large artery on the side of the neck) and not in the Brachiocephalic Vein as indicated by the sending facility.

The facility investigation of the incident did not identify the inconclusive reports by Radiology which did not confirm placement of the Central Line catheter prior to it being used. There was no documented evidence of actions to address issues related to questionable radiological findings.

On 07/25/19, at 12:15 PM during an interview with Staff F (RN, Vice President Patient Care Services) she acknowledged findings and stated that radiology contract was terminated.
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Based on medical record (MR) review, document review and interview in one (1) of ten medical record reviewed, the medical staff failed to ensure that the quality of care provided to each patient met prevailing standard of practice.

This failure may have placed patient at risk for harm.

Findings include:

Review of medical record #1 identified: An 84-year-old who presented to the Emergency Department (ED) on 3/15/19 with complaints of vomiting and diarrhea. Several attempts to insert a peripheral intravenous access for fluid and medication administration were unsuccessful. Staff J, the ED Physician placed a central line at 5:30PM. An order for chest X-Ray was written to confirm the placement of the Central line.

The chest x-ray report at 5:37 PM notes that the Central Line was "most likely in the left Brachiocephalic Vein (a large vein in the neck)."
At 8:09 PM, the patient was admitted to the Intensive Care Unit for a higher level of care. Another x-ray at 9:28 PM revealed that the "Central Line tip was probably in the Brachiocephalic Vein."

On 3/16/19 at 6:00 AM, a nurse noted that the patient developed a facial droop and a physician was notified. A CT scan (Special x-ray imaging) of the head revealed that the patient had suffered a stroke. The patient was transferred to another hospital for a higher level of care.

Review of patient's medical record from the receiving facility revealed that the Central line was placed in the left Carotid Artery (large artery on the side of the neck).

While the initial chest x-ray reports noted the catheter was "most likely" in the left Brachiocephalic Vein and the second report noted the catheter tip "was probably in the Brachiocephalic Vein", there was no definite confirmation of the catheter placement prior to its use for fluid and medication administration.

On 07/24/2019, at 10:44 AM, during interview with Staff J, ED physician, he stated that he used a sonogram prior to placement of the central line to identify the correct location but he did not use the sonogram to guide the insertion of the catheter.

On 7/30/19, at 02:23 PM, during interview with facility Staff F, Vice President of Patient Care Services, she reported that at the time of the incident of improper central line placement, the facility did not have a policy and procedure in place for confirmation of central line placement. However, clinicians who insert central lines are credentialed for the performance of the procedure. She further stated that clinicians who are credentialed can place central lines and are aware that an x-ray must be taken and read by a radiologist to confirm appropriate placement before the central line is used.
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