HospitalInspections.org

Based on document review and interview, the hospital failed to maintain an accurate and complete medical record (MR) including treatment, interventions, care provided and the patient's response to treatment, intervention or care for 1 of 10 MRs reviewed (P1).

Findings:

1. Review of policy PC-C-00027 indicated the following:
a. Safe management of central venous access devices (CVAD) will be maintained according to policy to prevent unnecessary complications in line maintenance.
b. The physician is responsible to order: (not all inclusive) timely discontinuation of catheter.
c. Removal of the CVAD may be ordered by the physician/LIP (licensed independent practitioner) in the event: Completion of therapy, change in therapy, patient or physician request, catheter complications.
d. Removal of a CVAD is appropriate when therapy is completed, as ordered by the LIP, for short peripheral or arterial catheter replacement, when contamination or complication is suspected, or when tip location is no longer appropriate for the prescribed therapy.
e. REMOVAL OF NONTUNNELED CVAD (physician to remove tunneled CVAD): (not all inclusive): Educate the patient in Valsalva ' s maneuver for all CVAD removal procedures. If a Valsalva ' s maneuver is contraindicated, have the patient exhale during the procedure. Apply pressure to site with gauze for a minimum of 30 seconds, or until hemostasis is achieved. This could take as long as 30 minutes or more depending on the patient ' s anticoagulation counts. Document date and time of catheter removal, condition of site, patient instruction, tip sent for culture (if done), and any other pertinent data in the patient ' s medical record.
f. Effective date: 10/1/15.

2. Review of patient MRs indicated patient P1 was an inpatient of the hospital from 8/11/16 to 8/22/16. Operative note dated 8/13/16 indicated the patient had a procedure for right femoral triple-lumen catheter placement due to need to IV (intravenous) access. Operative note dated 8/18/16 indicated the patient had procedure(s) as follows: 1. Attempted ultrasound-guided compression of right femoral pseudoaneurysm. 2. Ultrasound-guided thrombin injection of right femoral pseudoaneurysm. The indication for procedure was as follows: appears to have a right femoral pseudoaneurysm after removal of a triple-lumen catheter. The MR lacked documentation of the removal of the triple-lumen catheter (TLC), interventions related to the removal of the TLC, care provided following removal or patient response.

3. On 10/13/16 at 6:45pm, A7, Vice President/Chief Nursing Officer, indicated removal of a TLC/CVC (central venous catheter) may be performed by nursing or by a physician and that either discipline should document the procedure in the MR along with interventions and patient response.

4. On 10/13/16 at 6:45pm, A2, Clinical Quality Advisor, verified that the MR of P1 indicated a TLC was in place on 8/13/16, had been removed sometime prior to 8/18/18 and the MR lacked documentation of removal of the catheter, interventions used during and following removal or patient response.