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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 the following Patient's Rights; A 144 and A 145 for patient ID #1 with a retrained guide wire, and A 166, A 168, A 173, and A 175 for patients ID #'s 1, 5 and 21 with restraints.

Findings are as follows:

1. The facility failed to provide care in a safe setting for patient ID #1 related to insertion of a midline catheter. The facility failed to properly communicate and follow up on a significant finding on an x-ray and failed to include significant findings in the impression of the diagnostic imaging report. (Refer to A 144)

2. The facility failed to provide goods and services necessary to avoid physical harm or mental anguish for patient ID #1. The facility also failed to notify the ordering physician of the
finding of the retained guide wire. (Refer to A 145)

3. The facility failed to ensure that the use of restraints is in accordance with a written modification to the patient's plan of care for patient ID #21. (Refer to A 166)

4. The facility failed to obtain an order for a restraint from a physician or other licensed practitioner related prior to the application of the restraint, or in emergency application situations. The order must be obtained either during the emergency application of the restraint or immediately (within a few minutes) after the restraint has been applied, for patients ID #7, who was in restraints. (Refer to A 168)

5. The facility failed to ensure a physician's order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient be renewed per hospital policy for patients ID #1, who was restrained for more than 24 hours. (Refer to A 173)

6. The facility failed to ensure that the condition of the patient who is restrained, is monitored at an interval determined by hospital policy for patients ID #'S 1, 5, and 21. (Refer to A 175)


21613

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. Patient ID #1 had a midline catheter placed, after multiple unsuccessful attempts at a peripherally inserted central catheter (PICC). The facility failed to properly communicate and follow up on a significant finding on x-ray and failed to include a significant finding in the impression section of the diagnostic imaging report.

A midline catheter is inserted in a larger vein than those used for standard vascular therapy (IV). The tip is advanced no farther than the vein in the upper arm. The PICC is put into a large vein in the arm and ends in a large vein near the heart.

Findings are as follows:

Review of the Midline Catheter Insertion Policy, dated effective August 1st, 2016 revealed that a midline catheter kit is to be used for midline catheter insertion.

1. Record review for patient ID #1, revealed that he/she was admitted to the facility on 4/9/2018 with altered mental status, and signs of agitation and delirium. The patient was admitted to the Intensive Care Unit (ICU). IV access was limited due to his/her critical condition. After, multiple unsuccessful IV access attempts, an order for a PICC was obtained.

Review of the patient's record reveals that on 4/10/2018, Staff A, attempted to place a PICC line, a guide wire was utilized but attempts to advance the PICC line beyond the guide wire were unsuccessful. Staff A withdrew the PICC line, along with the guide wire and then reused the guide wire to convert to a midline catheter. Upon completion of the midline insertion, Staff A, failed to remove the guide wire from the patient's right arm

The surveyor interviewed the Director of Quality/Performance Improvement on 5/7/2018 at approximately 11:30 AM, he revealed that the nurse should not have used the same guide wire from the PICC insertion kit to insert a midline catheter.

The surveyor interviewed the Manager of the Infusion and IV Team (Staff F) and one of the nurses on the IV team (Staff C) on 5/8/2018 at 11:15 AM. They both confirmed that Staff A re-used the guide wire from the PICC insertion kit. The guide wire form the PICC kit is approximately 50 centimeter (cm) in length and the guide wire from the midline catheter insertion kit is approximately 8-10 cm in length. Staff F acknowledged that the staff on the IV team have used the guide wire from the PICC insertion kit to insert midline catheters in the past.

During a phone interview on 5/9/2018 at approximately 11:00 AM, the manufacturer's representative from the company which provides the PICC and midline insertion kits to the facility, stated that it was not acceptable to use the guide wire from the PICC insertion kit, for a midline placement.

The facility failed to follow the standard of practice for insertion of a midline catheter, by using the guide wire from the PICC kit which is significantly longer than a guide wire from the midline kit. Upon completion of the midline insertion, Staff A failed to remove the guide wire from the patient's right arm.

2. The facility failed to properly communicate and follow up on significant finding on x-ray as evidenced by the following;

Review of the record for this patient ID #1, revealed that he/she remained in the ICU on 4/10/2018, and had a physician's order for a routine chest x-ray.

Review of the "Final Report" for the chest x-ray reveals that the x-ray was performed at 4/11/2018 at 5:55 AM, and verified by sthe Radiologist (Staff D) at 8:59 AM.

The report states in part under sections:

FINDINGS; ..."There is a wire that ascends the region of the right internal jugular vein though the terminus is not visible on the image. Discussed with the practitioner caring for this patient at the time of dictation".

IMPRESSION; "No evidence of active pulmonary disease".

The surveyor interviewed the Radiologist (Staff D) on 5/8/2018 at approximately 10:30 AM, he revealed that he "spoke with the practitioner caring for the patient", however, he does not remember the name of the practitioner he spoke with. Staff D was unable to explain why the significant finding of the guide wire was not listed in the "Impression" section of the report, he only stated that the retained guide wire was documented in the "Findings" section of the report.

Stadd D stated that the reading room staff keeps a log of all calls placed to practitioners, however, review of the log for 4/11/2018 does not reveal a call being placed to the practitioner for patient ID #1 by the radiology staff.

The surveyor interviewed the Director of Diagnostic Imaging (Staff H) on 5/8/2018 at 10:40 AM, who stated that the name of the practitioner, and the date and time of the communication of the significant finding should have been documented by the person reading the diagnostic image.

The surveyor interviewed the Risk Manager on 5/9/2018 at 12:50 PM, who was unable to produce any evidence of communication from the radiologist to the ordering physician.

The record fails to reveal any follow up by any practitioner relative to the retained guide wire, noted on the 4/11/2018 x-ray.

The surveyors interviewed the ICU attending physician (Staff E) on 5/9/2018 at approximately 9:00 AM, who stated that on the day in question, there were 2 residents and 2 attending physicians in the ICU, and that no one recalls taking a call relative to patient ID #1 with a retained guide wire in his/her arm.

When asked about the x-ray report, from 4/11/2018, Staff E stated that they review the "Impression" and that the significant finding of the wire was not included in that section of the report. He also stated that in the past the ICU team would review the diagnostic images, however, that practice has been discontinued and the current practice is to review the reports not the images.

The surveyor also interviewed the ICU Resident (Staff G) on 5/9/2018 at 10:40 AM, who stated that she reviews the "Impression" section of the report, but does not review the "Findings" section of the report, which revealed the retrained guide wire. Staff G informed the surveyors that she has no recall of taking a phone call from anyone relative to a retained guide wire on patient ID #1.





21613

Based on record review and staff interview, it has been determined that the facility failed to provide goods and services necessary to avoid physical harm or mental anguish for patient ID #1, relative to the the retention of the guide wire.

Findings are as follows:

1. Record review for patient ID #1, revealed that he/she was admitted to the facility on 4/9/2018 with altered mental status, and signs of agitation and delirium. The patient was admitted to the Intensive Care Unit (ICU). The IV access was limited due to his/her critical condition. After, multiple unsuccessful IV access attempts, an order for a PICC was obtained.

On 4/10/2018, after three unsuccessful attempts to insert the PICC line, the IV nurse (Staff A) obtained an order to insert a midline catheter, and re-used the guide wire from the PICC line insertion. (Refer to A 144)

The record also reveals that the patient ID #1 remained in the facility, until he/she was discharged to home on 4/17/2018 without services. The Discharge summary section states "Pertinent Imaging and Results", "CXR 4/11: No evidence of active pulmonary disease" but fails to include the information relative to the retrained guide wire.

The patient returned to the Emergency Department (ED) on 4/24/2018, with a 2 day complaint of pain in the right upper extremity as well as right neck pain and headache. A chest x-ray at this time revealed the "presence of a wire/thin catheter extending from the right arm towards the mediastinum (chest) and upwards in the neck". A sonogram of the upper extremity was done and revealed evidence of Deep Vein Thrombosis (blood clot) of the brachial vein (arm),which was partially in the brachial vein and partially outside in the soft tissue".

Vascular surgery was consulted, and a heparin drip was initiated for treatment of the blood clot. The patient then underwent several attempts in interventional radiology to remove the wire, which was unsuccessful. Patient ID #1 went to the operating room on 4/25/2018 to undergo vascular surgery for removal of the guide wire.

The patient continued to have upper extremity weakness on the right side as a result of the retained guide wire, and required physical therapy (PT) and occupational therapy (OT), until he/she was discharged to home on 4/28/2018.

The patient returned to the facility on 4/30/2018 for rehabilitation services for right upper extremity weakness, numbness and swelling. The patient was discharged to home on 5/3/2018 with services.

The facility failed to provide services necessary to avoid physical harm or mental anguish for patient ID #1, when they used a guide wire not intended for use in the insertion of a midline catheter.
The facility failed to remove the guide wire and the patient was discharged to home with the retrained guide wire.

2. The facility failed to properly communicate and follow up on significant finding on x-ray.

Review of the "Final Report" for the chest x-ray reveals under sections;

FINDINGS; ..."There is a wire that ascends the region of the right internal jugular vein (neck) though the terminus is not visible on the image. Discussed with the practitioner caring for this patient at the time of dictation".

IMPRESSION; " No evidence of active pulmonary disease".

The surveyor interviewed the Radiologist (Staff D) on 5/8/2018 at approximately 10:30 AM, he stated that he "spoke with the practitioner caring for the patient" however he does not remember the name of the practitioner he spoke with, nor is it documented anywhere in the record. Additionally, he was unable to explain why the significant finding of the guide wire was not listed in the Impression section of the report.

Review of the radiology logs, lacked evidence of the Radiologist notifying the significant finding of the guide wire to the the ordering physician.

The surveyor interviewed the Director of Diagnostic Imaging (Staff H) on 5/8/2018 at approximately 10:40 AM, who stated that the name of the practitioner, and the date and time of the communication of the significant finding should have been documented by the person reading the diagnostic image.

3. The surveyors interviewed the ICU attending physician (Staff E) on 5/9/2018 at approximately 9:00 AM, who stated that on the day in question, there were 2 residents and 2 attending physicians in the ICU, and that no one recalls taking a call relative to patient ID #1 with a retained guide wire in his/her arm.

When asked about the x-ray report, from 4/11/2018, Staff E stated that they review the "Impression" and that the significant finding of the wire was not included in that section of the report. He also stated that in the past the ICU team would review the diagnostic images, however, that practice has been discontinued and the current practice is to review the reports not the images.

The surveyor also interviewed the ICU Resident (Staff G) on 5/9/2018 at 10:40 AM, who stated that she reviews the "Impression" section of the report, but does not review the "Findings" section of the report, which revealed the retrained guide wire. Staff G, informed the surveyors that she has no recall of taking a phone call from anyone relative to a retained guide wire on patient ID #1.




21613

21613

Based on record review and staff interview, it has been determined that the facility has failed to ensure that the use of the restraint is in accordance with a written modification to the patient's plan of care for 1 of 5 patients (ID #21).

Findings are as follows;

Record review for patient ID #21 revealed the patient was admitted to the facility on 3/29/2018 for agitation and an abnormally rapid heart rate. The patient has behavioral issues, including but not limited to aggression and combative behavior with care, and a history of developmental disability.

Review of the record revealed the following;

-On 4/28/2018, the patient was agitated, thrashing in bed and trying to climb over the side rails.

A physician's order dated 4/28/2018 at 12:03 AM, states "Wrist restraint, left" for cognitive impairment interferes with care.

Review of the restraint activity sheets revealed the patient has soft restraints applied to both left and right wrists on 4/28/2018 between 12:00 AM and 9:45 AM.

-On 5/3/2018, the patient was very restless, kicking, attempting to climb out of bed, and remove clothes, staff was unable to redirect the patient.

A physician's order dated 5/3/2018 at 12:44 AM, states "Ankle restraint, left" for unaware of potential for self-harm.

Review of the restraint activity sheets revealed the patient has soft restraints applied to both left and right wrists on 5/3/2018 between 12:30 AM to 6:00 AM, and between 4:00 PM to 11:00 PM.

-On 5/4/2018, the patient was agitated and restless. The patient lifting his/her legs and trying to kick when staff come close to the bedside.

A physician's order dated 5/4/2018 at 12:00 AM, states "Wrist restraint, left" for cognitive impairment interferes with care.

Review of the restraint activity sheets revealed the patient has soft restraints applied to both left and right wrists on 5/4/2018 between 1:00 AM to 5:00 AM.

During an interview with the nurse manager of the unit (staff O) on 5/10/2018 at 2:40 PM, she was unable to explain why the restraints were not applied in accordance with the physician's orders.

21613

Based on record review and staff interview, it has been determined that the facility has failed to obtain an order for a restraint from a physician or other licensed practitioner, prior to the application of restraint or in emergency application situations, the order must be obtained either during the emergency application of the restraint, or immediately (within a few minutes) after the restraint has been applied, for 1 of 5 patients (ID #7) who was in restraints.

Findings are as follows;

Record review for patient ID #7 revealed the patient arrived in the Emergency Department (ED) via emergency medical services on 5/8/2018. Upon arrival to the ED, the patient was agitated and uncooperative and he/she was placed on soft wrist restraints for safety at 8:30 PM.

Record review revealed the physician's order was not obtained for restraints until 11:07 PM on 5/8/2018.

During an interview on 5/9/2018 at approximately 2:30 PM, the Quality Improvement (Staff P) was unable to explain why the order for restraint was not obtained either during the emergency application of the restraint or immediately (within a few minutes) after the restraint has been applied.

21613

Based on record review and staff interview, it has been determined that the facility has failed to ensure a physician's order for restraint used to ensure physical safety of the non-violent or non-self-destructive patient be renewed per hospital policy, for 1 of 3 patients who was restrained for more than 24 hours (patient ID #1).

Findings are as follows;

The hospital's policy and procedure for Restraint Use, states in parts under procedure;

" 1) Restraint Order...

c. Restraint orders must be re-evaluated/renewed daily..."

Record review for patient ID #1 revealed the patient presented in the Emergency Department (ED) on 4/8/2018 with altered mental status and signs of agitation and delirium. Upon arrival to the ED, he/she was uncooperative and agitated.

Record review revealed a physician's order dated 4/8/2018 obtained at 11:30 PM indicates soft restraints to both of his/her wrists and both of his/her ankles. The patient was placed on the restraints for agitation, self-harm, restless and trashing in bed on 4/8/2018 at 11:45 PM.

Record review revealed the physician's order for restraint was renewed on 4/9/2018 at 11:26 PM, however, there lacked evidence that the order for restraint was renewed on 4/10/2018.

During an interview with the Director of Quality/Performance Improvement on 5/9/2018 at 11:45 AM, he acknowledged that the order for the restraints was not renewed daily according to the hospital's policy.

21613

Based on record review and staff interview, it has been determined that the facility has failed to ensure that the condition of the patient who is restrained, is monitored at an interval determined by the hospital policy for 3 of 5 patients (patient ID #'s 1, 5 and 21).

Findings are as follows;

The hospital's policy and procedure for Restraint Use, states in parts;

" ...
c. The patient will be assessed/re-assessed at least every 2 hours to include review of neurological, circulatory and integumentary system (skin, hair, nails, glands and nerves), the patient response to being restrained and treatment provided. These are documented in the electronic medical record ..."

1. Record review for patient ID #1 revealed the patient presented in the Emergency Department (ED) on 4/8/2018 with altered mental status and signs of agitation and delirium. Upon arrival to the ED, he/she was uncooperative and agitated. A physician's order dated 4/8/2018 obtained at 11:30 PM indicates soft restraints to both of his/her wrists and both ankles.

Review of the restraint activity sheets dated 4/9/2018 revealed that between the hour of 5:45 AM and 3:21 PM, the assessment was not done every 2 hours.

Review of the restraint activity sheet dated 4/10/2018 revealed that between the hour of 6:45 AM and 11:29 AM, the assessment was not done every 2 hours.

2. Record review for patient ID #5 revealed the patient presented in the ED on 5/6/2018 due to an acute exacerbation of lung disease. The patient was subsequently intubated and admitted to intensive care unit (ICU). Record review revealed a physician's order for restraint was renewed on 5/7/2018, 5/8/2018 and 5/9/2018.

Review of the restraint activity sheets dated 5/7/2018 revealed that between the hour of 10:00 AM and 4:02 PM, the assessment was not done every 2 hours.

Additionally, a review of the restraint activity sheets dated 5/8/2018 revealed that between the hour of 3:00 AM and 2:38 PM, the assessment was not done every 2 hours.

Review of the restraint activity sheet on 5/9/2018 at 12:30 PM revealed no evidence that the patient has been assessed every 2 hours between 8:00 AM and 12:30 PM per the hospital's policy

During an interview with the patient's nurse (Staff I) on 5/9/2018 at 12:40 PM, she was unable to produce evidence that the patient has been assessed every 2 hours per the hospital's policy.

During an interview with the ICU Nurse Manager on 5/10/2018 at 12:13 PM, she was unable to produce evidence that the restraint assessment was completed every 2 hours per the hospital's policy.

3. Record review for patient ID #21 revealed the patient was admitted to the hospital on 3/29/2018 for abnormally rapid heart rate. The patient has behavioral issues, including but not limited to aggressive and combative with care and a history of developmental disability.

Review of the restraint activity sheets dated on 5/8/2018 revealed that between the hour of 1:00 AM and 4:02 PM, the assessment was not done every 2 hours.

During an interview with the nurse manager of the unit (staff O) on 5/10/2018 at 2:40 PM, she was unable to produce evidence that the restraint assessment was done every 2 hours per the hospital's policy.

21613

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 the hospital policy for patient ID #1, who had a midline catheter insertion.

Findings are as follows;

Review of the Midline Catheter Insertion Policy, dated effective August 1st, 2016 revealed that a midline catheter kit to be used for midline catheter insertion.

Record review for patient ID #1, revealed that he/she was admitted to the facility on 4/9/2018 with altered mental status, and signs of agitation and delirium. The patient was admitted to the Intensive Care Unit (ICU). IV access was limited due to his/her critical condition. After, multiple unsuccessful IV access attempts, an order for a PICC was obtained.

Review of the patient's record revealed that on 4/10/2018, Staff A, attempted to place a PICC line, a guide wire was utilized but attempts to advance the PICC line beyond the guide wire were unsuccessful. Staff A withdrew the PICC line, along with the guide wire and then reused the guide wire to convert to a midline catheter. Upon completion of the midline catheter insertion, Staff A failed to remove the guide wire from the patient's right arm.

A hospital self-report indicates the midline was maintained and used for IV therapy for approximately 20 hours. During a routine x-ray, the following morning (4/11/2018), it was noted that there was a wire ascending the region of the right internal jugular vein (biggest vein of the neck). The radiology report suggests this finding was discussed with the practitioner caring for the patient at the time of the dictation. There is no documentation in the ICU progress notes indicating that a conversation had occurred. The patient was subsequently transferred to a general medical unit and discharged to home on 4/17/2018.

A hospital self-report also indicates that on 4/24/2018, the patient returned to the Emergency Department (ED) with complaints of ongoing right arm pain and a headache along with change in mental status, lethargy, restlessness and agitation.

Record review revealed that an evaluation in the ED with chest x-ray revealed the presence of a wire or thin catheter extending from the right arm towards the mediastinum (chest) and upwards in the neck. A sonogram of the right upper arm was done which revealed evidence of deep vein thrombosis (blood clot) of brachial vein (upper arm). There appeared to be a catheter partially in the brachial vein and partially outside in the soft tissues of the upper arm but not extending to the skin surface. Medications were administered to treat the blood clots. The patient went to interventional radiology to remove the wire but they were unable to do so. The patient underwent vascular surgery for removal of the wire on 4/25/2018.

Review of the record revealed the patient continued to have right upper arm weakness. The patient received physical therapy and occupational therapy and was discharged home on 4/28/2018. The discharge summary also revealed that the patient would continue to take a blood thinner medication for a minimum of 3 months.

Record review revealed that the patient returned to the hospital on 4/30/3218 for admission for rehabilitation for the right upper arm weakness, numbness and swelling and the patient was discharged to home on 5/3/2018.

The surveyor interviewed the Director of Quality/ Performance Improvement on 5/7/2018 at approximately 11:30 AM, who revealed that the nurse should not have used the guide wire from the PICC insertion kit for the midline insertion.

The surveyor interviewed the Manager of the Infusion and IV Team (Staff F) and one of the nurses on the IV team (Staff C) on 5/8/2018 at 11:15 AM. They both confirmed that staff A re-used the guide wire from the PICC insertion Kit. The guide wire form the PICC kit is approximately 50 cm in length and the guide wire from the midline catheter insertion kit is approximately 8-10 cm in length. Staff F acknowledged that the staff on the IV team have used the guide wire from the PICC insertion kit to insert midline catheters in the past.

Although, the Manager of the infusion and IV Team (Staff F) was aware that IV team staff have used the the guide wire from a failed PICC insertion to insert a midline catheter in the past, she failed to ensure that the facility's policy for midline insertion was followed.

During a phone interview on 5/9/2018 at approximately 11:00 AM, the manufacturer's representative from the company which provides the PICC and Midline insertion kits to the facility, stated that it was not acceptable to use the guide wire from the PICC insertion kit, for a midline placement.

The facility failed to follow the standard of practice for insertion of a midline catheter, by using the guide wire from the PICC kit which is significantly longer than a guide wire from the midline kit. Upon completion of the midline, Staff A failed to remove the guide wire from the patient's right arm.

As a result of the failure to remove the guide wire, the patient returned to the ED with complaints of ongoing right arm pain and a headache along with change in mental status, which required further hospitalization with interventions to remove the retrained guide wire.