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Based on interview and record review, the facility failed to follow its policy and procedure when the Emergency Department (ED) Medical Doctor (MD 1) did not order an X-ray (a test that creates pictures of the inside of the body) for the central line (a tube that is passed through a vein to give fluids and medications) placement confirmation for Patient 2. MD 1 documented in Patient 2's clinical record that the guidewire (device used to enter tight spaces) had been removed.

This failure resulted in a retained (left behind) guidewire in Patient 2 and had a potential for further harm.

Findings:

A review of the Face Sheet, dated 5/3/20, indicated Patient 2 was admitted for respiratory failure and pulmonary edema (excess fluid in the lungs).

A review of the ED Report dated 5/3/20, indicated MD 1 placed a central line for Patient 2. The ED Report indicated MD 1 retrieved and disposed of the guidewire. This was documented by MD 1.

During an interview on 5/13/21 at 10:50 a.m., the Director of Performance Improvement (DPI) stated MD 1 did not obtain a chest x-ray (a test that produces pictures of the lungs, heart and chest) for Patient 2 to verify the central line placement. The DPI further stated that MD 1 did not remove the guidewire after the central line placement but documented in Patient 2's clinical record that the guidewire had been removed.

A review of the discharge summary, dated 5/4/20, indicated Patient 2 was transferred to Facility 2 on 5/4/20.

A review of Facility 2's letter, dated 10/13/20, indicated Patient 2 was transferred to their facility on 5/4/20 with a central line upon arrival. According to the facility letter, Patient 2 was discharged from the facility on 5/7/20. Per the facility letter, Patient 2 presented to facility 2 on 9/14/20 for a CT (Computed Tomography; uses computers and rotating x-rays to create images of the body) guided biopsy (guides needle to collect tissue sample), however the biopsy was cancelled due to the appearance of a guidewire, which had been in place for over four months. Per the facility letter, the chest and abdominal x-rays were interpreted by the Radiologist (MD 2) and Patient 2 was discharged home. Additionally, the facility letter indicated Patient 2 presented back to the facility on 9/16/20 for removal of the foreign body (central line guide wire) which was removed by MD 2 with no complications and Patient 2 was discharged home on the same day.

During a concurrent interview and record review of Facility 2's letter on 5/13/21 at 10:55 a.m., the DPI confirmed the above findings.

During a review of the facility's policy and procedure (P&P) titled, "Central Venous (CVC) Insert, Care, DC," revised 12/2019, the P&P indicated, "Obtain chest x-ray for proper confirmation of placement prior to use."

During a review of the facility's Medical Bylaws, undated, Article III, Section 3.3 indicated, "Basic Responsibilities of Staff Membership: Each member of the Medical Staff and each practitioner granted temporary privileges shall, abide by the Medical Staff Bylaws, Staff Rules and Regulations, department rules and regulations, applicable laws and regulations of governmental agencies and requirements of the Joint Commission (TJC) and policies of the Hospital to the extent the policies have been approved by the Medical Executive Committee."

Based on interview and record review, the facility failed to ensure adequate ventilation (the exchange of oxygen between the lungs) by assuring patency of patient's airway for one sampled patient (Patient 1 of 30) who was unable to maintain their own airway and prevent hypoxemia (a low level of oxygen in the blood) and hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) by extubating the patient (removal of the endotracheal tube).

This failure resulted in a situation whereby Patient 1 was unable to breathe on her own and went into cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness) and died.

Findings:

A review of the medical record titled, "History and Physical" dated 1/14/21, indicated Patient 1 was admitted to the facility on 1/14/21 with diagnoses that included history of Diabetes (too much sugar in the blood system) and a worsening shortness of breath.

A review of laboratory test result dated 1/16/21, indicated Patient 1 tested positive for Covid-19 (infection caused by a coronavirus).

A review of document titled "Medical Notes" dated 2/10/21, indicated Patient 1 was intubated (a procedure that's used when you can't breathe on your own) due to continuous labored breathing.

During an interview with the Director of Performance Improvement (DPI) on 5/12/21 at 1:55 p.m., the DPI confirmed Patient 1 was intubated because of ineffective breathing induced by Covid-19. The DPI further explained that during this time, Patient 1 had three Code Blue episodes (a hospital emergency code used to describe the critical status of a patient), and after the third episode, Patient 1 was stabilized. The DPI explained that Nurse Practitioner (NP 1) then stepped out of the room to inform the family of Patient 1's status while the Respiratory Therapist (RT 1) monitored Patient 1. The Registered Nurse (RN) also left the room briefly and came back to see that RT 1 had extubated the patient. Immediately, NP 1 came back into the room and also found that the RT had extubated the patient. When NP 1 asked the RT why he extubated patient, RT mentioned he assumed Patient 1 was pronounced dead and was ok to be extubated. They attempted to resuscitate the patient again but Patient 1 went into asystole (the most serious form of cardiac arrest which is usually irreversible) and was pronounced dead.

During an interview with NP 1, on 5/13/21 at 2:10 p.m., he stated that after responding to Patient 1's third Code Blue and stabilizing the patient, he stepped out of the room briefly to explain to the family about the current situation. When he returned, he found that the RT had extubated the patient and when he was asked why he did it, RT stated he thought Patient 1 had been pronounced dead.

During a concurrent interview with DPI and Director of Medical Staff Services (DMSS), on 5/12/21 at 2:33 p.m., both agreed that the facility did not follow protocols with extubating Patient 1 and conceded that the action by the RT led to Patient 1's death.

A review of Facility Policy and Procedure last reviewed 9/2019, titled "Extubation,".. the Purpose Statement indicated the policy was to ensure adequate ventilation by assuring patency of patient's airways in those patients unable to maintain their own, and to prevent hypoxemia and hypoxia.