HospitalInspections.org

Based on document review and interview, it was determined for 1 of 1 (Pt #3) clinical record reviewed for patient with central line, the Hospital failed to ensure reassessment was completed after placement of patient's central line.

Findings include:

1. Policy title "Reassessment" (effective 7/30/02) required, "...7. Nursing conducts daily reassessment of the patient's condition as documented on appropriate documentation tool... 10. When there is a significant change in the patient's condition, a full reassessment is performed. Such as but not limited to: ... To determine response to certain treatment. "

2. On 3/14/16 at approximately 1:00 PM, a clinical record review of Pt. #3 was done. Pt. #3 was a 42 year old admitted on 2/19/16 with a diagnosis of stroke. A physician progress note dated 3/10/16 at 6:11 PM included, "The patient has a peripherally inserted central line (PICC)." The catheter was placed on 3/10/16. However, the nursing assessment or reassessment did not indicate Pt. #3 had a PICC line until 3/12/16.

3. On 3/15/16 at approximately 9:00 AM, an interview was conducted with the Chief Nursing officer who agreed that documentation was not done for Pt. #3's PICC line until 3/12/16.