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Based on record review and staff interviews, it has been determined that the facility continues to fail to meet the Condition of Participation relative to Patient's Rights for patient ID #'s 1, 7, 13 and 14 who had a central venous line insertion (a catheter that is inserted into a large vein for administration of medications or fluids).

Findings are as follows:

1. The facility failed to provide care in a safe setting related to Central Venous Line Insertion. The facility failed to complete a Central Line Insertion Checklist per the hospital policy for patients ID #'S 1, 7 and 14.

2. The facility failed to ensure that the Central Line tip locations were confirmed by x-ray prior to accessing per the hospital policy for patients ID#'s 1, 7 and 13.

(refer to A 144)

Based on record review and staff interviews, it has been determined that the facility failed to ensure that the patient has the right to receive care in a safe setting related to central venous line insertion. The facility failed to complete a Central Line (CL) Insertion Checklist per the hospital policy for patients ID #'S 1, 7 and 14. Additionally, the facility failed to ensure that the central line tip locations were confirmed by x-ray prior to accessing per the hospital policy for patients ID#'s 1, 7 and #13.

Findings are as follows:

Review of the "Central Venous Line Insertion Post Insertion Care" Policy, dated effective November 4, 2016 states in part;

Under Definitions

" ...Central Venous Line - A catheter introduced via a large vein and terminates at or close to the heart or in one of the great vessels which is used for infusions, withdrawal of blood,...

High Risk Central Line (HR CL) - A central line is considered high risk when any of the following conditions occur during the insertion or maintenance of the line...

c. there is missing documentation such as a central line insertion check list..."

Under Procedure

"...c. The team member assisting the inserting Physician, Resident, or PA (Physician Assistant) will complete a Central Line Insertion Checklist verbally with the inserting provider prior to skin puncture, and during the procedure,...

d. The CL Insertion Checklist will be completed...

t. Central Line tip location must then be confirmed by CXR (chest x-ray) prior to accessing ..."

1. Record review for patient ID #1, revealed that the patient presented in the Emergency Department (ED) of this facility (Hospital A) on 5/19/5018 with worsening abdominal pain, vomiting as well as complaining of a tender mass on the buttock area.

The record review revealed the patient required a right femoral (thigh) central venous catheter placed on 5/20/2018.

There lacked evidence that an x-ray was done to confirm the tip of the location of the catheter per the hospital policy.

The record indicates the patient was treated with antibiotic for infection on the buttock area. The central line remained patent and was removed in anticipation of the patient discharged home on 5/22/2018.

The record indicated the patient presented to another facility (Hospital B) on 5/29/2018 and the patient was found to have high blood sugar. Because the patient usually has difficult intravenous (IV) access, a central line was placed in the right jugular vein (neck). An x-ray was done to confirm placement of the line. Staff noted that the patient has a retained guide wire in a vein near the heart. The x-ray revealed that this wire extended from the medial neck to the abdomen. The patient reported that she/he had been at Hospital A at approximately 1 week ago, where she/he had a right femoral central line placement.

Record review revealed the patient was transferred back to Hospital A on 5/30/2018 for an evaluation and removal of the retained guide wire.

Review of the hospital's History of Present Illness(Hospital A) dated 5/30/2018 indicates "it seemed that this wire is from the prior femoral line that was placed last admission". The patient was taken to interventional radiology and the guide wire was removed on 5/30/2018.

During an interview on 6/5/2018 at 3:40 PM, Nurse B stated she assisted the physician (Resident A) with the femoral line insertion that was done on 5/20/2018. At the end of the procedure, she walked to the door to ask another staff for a dressing kit. When she returned to the patient bedside the femoral line insertion had been completed. A dressing was applied to the site. Nurse B revealed she did not see the removal of the guide wire and she did not verify with the physician that the guide wire had been removed, however, she documented on the check list that the guide wire was removed and intact.

The surveyor interviewed the Director Quality/Performance Improvement and the Director of Risk Management on 6/6/2018 at approximately 10:00 AM, they were unable to produce evidence that the x-ray was obtained to confirm the femoral line tip location per the facility policy. Additionally, the Director of Risk Management confirmed that although, Nurse B did not see the removal of the guide wire, Nurse B documented that the guide wire was removed and intact.

2. Record review for patient ID #7 revealed the patient presented in the ED on 5/9/2018 with abdominal pain.

Review of the "Final Report" of the Line Placement Procedure dated 5/9/2018 revealed there were 2 failed attempts to place the central line into the patient's right jugular vein, therefore, the central line was placed into the patient's right femoral (thigh) vein .

There lacked evidence that the x-ray was done to confirm the tip of the location of the catheter after the procedure was completed. There also lacked evidence that the check list was completed for the central line insertions that were attempted in the patient's right jugular vein.

3. Record review for patient ID #13 revealed the patient presented in the ED on 5/29/2018 status post fall and head injury and a central line was placed into the patient's right femoral vein.

There lacked evidence that an x-ray was done to confirm the tip of the location of the catheter after the procedure was completed.

4. Record review for patient ID #14 revealed the patient presented in the ED on 5/30/2018 with lethargy (sleepy or fatigued and sluggish) and chronic pressure wound. A central line insertion was attempted on the patient's right femoral vein but the physician was unable to cannulate, therefore, the central line was placed into the patient's left femoral vein.

There lacked evidence that the check list was completed for the attempted central line insertions of the right femoral vein.

During an interview with the Director of Emergency Department on 6/8/2018 at 10:30 AM, he revealed the central line check lists should be completed, even though, the insertion was unsuccessful.

The surveyor interviewed the Director Quality/Performance Improvement and the Director of Risk Management on 6/8/2018 at approximately 11:00 AM, they were unable to produce evidence that the x-ray was obtained to confirm the femoral line tip location and the central line check lists were completed per the facility policy.

Based on record review and staff interviews, it has been determined that the facility has failed to provide nursing care in accordance with accepted standards of nursing practice and hospital policy for patient ID #1, who had a central line insertion.

Findings are as follows:

Review of the "Central Venous Line Insertion Post Insertion Care" Policy, dated effective November 4, 2016 states in part;

Under Definitions

" ...Central Venous Line - A catheter introduced via a large vein and terminates at or close to the heart or in one of the great vessels which is used for infusions, withdrawal of blood,..."


Under Procedure

"...c. The team member assisting the inserting Physician, Resident, or PA (Physician Assistant) will complete a Central Line Insertion Checklist verbally with the inserting provider prior to skin puncture, and during the procedure,..."


Record review for patient ID #1, revealed that the patient presented in the Emergency Department (ED) of this facility (Hospital A) on 5/19/5018 with worsening abdominal pain, vomiting as well as complaining of a tender mass on the buttock area.

The record review revealed the patient required a right femoral (thigh) central venous catheter placed on 5/20/2018. The patient was treated with antibiotic for infection on the buttock area. The central line remained patent and was removed in anticipation of the patient discharged home on 5/22/2018.

The record indicated the patient presented to another facility (Hospital B) on 5/29/2018 and the patient was found to have high blood sugar. Because the patient usually has difficult intravenous (IV) access, a central line was placed in the right jugular vein (neck). An x-ray was done to confirm placement of the line. Staff noted that the patient has a retained guide wire in a vein near the heart. The x-ray revealed that this wire extended from the medial neck to the abdomen. The patient reported that she/he had been at Hospital A at approximately 1 week ago where she/he had a right femoral central line placement.

Record review revealed the patient was transferred back to Hospital A on 5/30/2018 for an evaluation and removal of the retained guide wire.

Review of the hospital's History of Present Illness (Hospital A) dated 5/30/2018 indicates "it seemed that this wire is from the prior femoral line that was placed last admission". The patient was taken to interventional radiology and the guide wire was removed on 5/30/2018.

During an interview on 6/5/2018 at 3:40 PM, Nurse B stated she assisted the physician (Resident A) with the femoral line insertion that was done on 5/20/2018. At the end of the procedure, she walked to the door to ask another staff for a dressing kit. When she returned to the patient bedside the femoral line insertion had been completed. A dressing was applied to the site. Nurse B revealed she did not see the removal of the guide wire and she did not verify with the physician that the guide wire had been removed, however, she documented on the check list that the guide wire was removed and intact.

The surveyor interviewed the Director Quality/Performance Improvement and the Director of Risk Management on 6/6/2018 at approximately 10:00 AM, they were unable to produce evidence that the that the facility has provided nursing care in accordance with accepted standards of nursing practice and the hospital policy, when nurse B did not verify the removal of the guide wire for patient ID #1.

(refer to A 144)