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PALMS WEST HOSPITAL 13001 SOUTHERN BLVD LOXAHATCHEE, FL 33470 June 26, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to provide nursing services according to nursing policies and procedures when removing a central venous catheter in 1 of 10 sample patients, (Patient #5).

The findings included:

On 08/08/16, the clinical record revealed Patient #5 was admitted for a narcotic overdose, non-cardiogenic pulmonary edema, respiratory distress and Rhabdomyolysis. The patient was intubated in the emergency room and admitted to the Intensive Care Unit (ICU).

On 08/15/16, the Critical Care Progress note, revealed Patient #5 was successfully liberated from the ventilator and was stable for transfer out of ICU.

On 08/18/16 at 10:35 AM, the clinical notes revealed Patient #5 was able to ambulate and performed standing exercises by the edge of his bed with no loss of balance. The patient was alert, talking and eating.

On 08/18/16 at 1:15 PM, the nurses notes revealed the Left Intravascular Jugular (LIJ) catheter was removed without difficulty. The patient started to complain about burning in the middle of his chest with associated shortness of breath and diaphoresis. The patient's oxygen saturation (pulse oximeter reading) dropped to the 70's. The patient was placed back in bed.

On 08/18/16 at 2:20 PM, the critical care progress note by the physician revealed Patient #5 suddenly became very agitated, hypoxemic, and oxygen saturation dropped to 70% after removal of Central Venous Line from Left Intravascular Jugular per the Registered Nurse (RN). The patient was intubated for respiratory failure. The nursing note revealed: will get a chest x-ray stat - suspect air embolism / pulmonary embolism. The patient was placed on a ventilator.

On 08/21/16 at 2:06 PM, the hospitalist note revealed the prognosis is guarded; Patient is off sedatives, currently unresponsive, in deep coma from anoxic brain [DIAGNOSES REDACTED]; No corneal reflexes; Highly likely brain death; and the family declined any further tests, requested to proceed with withdrawal of care in AM.

Review of the Brief Death Summary Note, dated 08/22/16, revealed the patient passed away at 8:50 AM with the parents at the bedside.

Review of the Autopsy Report revealed the cause of death as complications of probable air embolism following removal of central venous catheter due to treatment of opiate overdose.

During an interview with Staff A (a registered nurse), on 06/26/17 at approximately 10:00 AM, she stated that she has been a registered nurse (RN) for 31 years. She stated that she has been working at this hospital since October 2014, in the Intensive Care Unit (ICU). She stated that Patient #5 was in the Intensive Care Unit (ICU) and she was assigned to care for the patient. She stated the patient was sitting in the chair and a family member was in the room. She stated she took out the central venous catheter while the patient was sitting in the chair. She stated that removing the line while the patient was sitting in a chair is not the appropriate way. She stated the appropriate way is to have the patient lay down flat in the bed and hold their breath. She stated the patient, all of a sudden, grabbed his chest and said he was having a lot of pain. She stated that the patient was breathing, and she and another nurse helped the patient stand and get into his bed. She stated the intensivist intubated the patient.

During an interview with the Director of the ICU, on 06/26/17 at approximately 9:45 AM, she stated that Staff A's action of removing the central venous line while the patient was sitting in a chair, was very surprising. She stated that when she was made aware of the autopsy report in January 2017, she spoke to Staff A and told her there was a possibility the patient expired due to the pulling of the central line while the patient was sitting up in a chair. She stated that Staff A admitted removing the line while the patient was sitting up in a chair. She stated the appropriate way and according to hospital policy is to have the patient in a Trendelenburg position, not sitting upright in a chair.

During an interview with the Chief Nursing Officer, on 06/26/17 at approximately 3:00 PM, she stated that she was informed about this case when the autopsy results came back in January. She stated that she does not remember who told her or who was involved in making the decision to not initiate an incident report when they found out about the autopsy report.

Review of the policy and procedure for the removal of Removal of Central Venous Catheters includes: 'place the patient in Trendelenburg position, if not contraindicated. Turn head to opposite side of central line.'
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to supervise and evaluate the nursing care in accordance with hospital policy in removing a central venous catheter in 1 of 10 sample patients, (Patient #5).

The findings included:

On 08/08/16, the clinical record review revealed Patient #5 was admitted for a narcotic overdose, non-cardiogenic pulmonary edema, respiratory distress and Rhabdomyolysis. The patient was intubated in the emergency room and admitted to the Intensive Care Unit (ICU).

On 08/15/16, the Critical Care Progress note, revealed Patient #5 was successfully liberated from the ventilator and was stable for transfer out of ICU.

On 08/18/16 at 10:35 AM, the clinical notes revealed the patient was able to ambulate and performed standing exercises by the edge of his bed with no loss of balance. He was alert, talking and eating.

On 08/18/16 at 1:15 PM, the nurses notes revealed the Left Intravascular Jugular (LIJ) catheter was removed without difficulty. The patient started to complain about burning in the middle of his chest with associated shortness of breath and diaphoresis. The patient's oxygen saturation (pulse oximeter reading) dropped to the 70's. The patient was placed back in bed.

On 08/18/16 at 2:20 PM, the critical care progress note by the physician revealed the patient suddenly became very agitated, hypoxemic, and the oxygen saturation dropped to 70% after removal of Central Venous Line from Left Intravascular Jugular per the Registered Nurse. The patient was intubated for respiratory failure. The note revealed: will get a chest x-ray stat - suspect air embolism / pulmonary embolism. The patient was placed on a ventilator.

On 08/21/16 at 2:06 PM, the hospitalist note revealed the prognosis is guarded; Patient is off sedatives, currently unresponsive, in deep coma from anoxic brain [DIAGNOSES REDACTED]; No corneal reflexes; Highly likely brain death and the family declined any further tests, and requested to proceed with withdrawal of care in AM.

Review of the Brief Death Summary Note of 08/22/16 revealed the patient passed away at 8:50 AM with the family members at the bedside.

Review of the Autopsy Report revealed the cause of death as complications of probable air embolism following removal of central venous catheter due to treatment of opiate overdose.

During an interview with Staff A, a registered nurse, on 06/26/17 at approximately 10:00 AM, she stated that she has been a registered nurse (RN) for 31 years. She stated that she has been working at this hospital since October 2014, in the Intensive Care Unit (ICU). She stated that Patient #5 was in the Intensive Care Unit (ICU) and she was assigned to care for the patient. She stated the patient was sitting in the chair and a family member was in the room. She stated she took out the central venous catheter while the patient was sitting in the chair. She stated that removing the line while the patient was sitting in a chair is not the appropriate way. She stated the appropriate way is to have the patient lay down flat in the bed and hold their breath. She stated the patient, all of a sudden, grabbed his chest and said he was having a lot of pain. She stated that he was breathing and she and another nurse helped the patient stand and get into his bed. She stated the intensivist intubated the patient.

During an interview with the Director of the ICU, on 06/26/17 at approximately 9:45 AM, she stated that Staff A's action of removing the central venous line while the patient was sitting in a chair, was very surprising. She stated that when she was made aware of the autopsy report in January 2017, she spoke to Staff A and told her there was a possibility the patient expired due to the pulling of the central line while the patient was sitting up in a chair. She stated that Staff A admitted removing the line while the patient was sitting up in a chair. She stated the appropriate way and according to hospital policy is to have the patient in a Trendelenburg position, not sitting in a chair.

During an interview with the Chief Nursing Officer, on 06/26/17 at approximately 3:00 PM, she stated that she was informed about this case when the autopsy results came back in January. She stated that she does not remember who told her or who was involved in making the decision to not initiate an incident report when they found out about the autopsy report.

Review of the policy and procedure for the removal of Removal of Central Venous Catheters includes: 'place the patient in Trendelenburg position, if not contraindicated. Turn head to opposite side of central line.'