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GRACE COTTAGE HOSPITAL PO BOX 216 TOWNSHEND, VT 05353 Jan. 22, 2020
VIOLATION: NURSING SERVICES Tag No: C1046
Based on interview and record review the CAH failed to ensure that nursing staff was adequately trained and competent with central venous access care/maintenance and IV medication administration for 1 applicable patient in the sample (Patient #1). Findings include:

Per record review Patient #1 has a history of anemia and iron deficiency. On 8/30/19, s/he underwent a surgically placed right subclavian chem port (a small, implantable reservoir with a thin silicone tube that attaches to a vein.) for iron infusion. On 9/12/19, Patient #1 arrived at the hospital for his/her first iron infusion. Per review of a nursing progress note from 9/12/19 at 9:42 AM it read, "Complication during the placement of first Huber (a specially designed hollow needle used with a port.) needle. Patient's port is deeper ... ...Port visualized by ultrasound .... Patient given injection lidocaine by ER provider ......Patient had burning sensation ......with saline (a solution of salt in water) flush and with heparin (anticoagulant) lock .... No s/s of infiltration at the site. Patient will be back for next infusion on Monday". A nursing progress note from 9/16/19 at 11:05 AM, read, "Arrived to assist with difficult MP (port) access. Attempts x 2, Pt articulated that there was a difficult access attempt at last outpatient visit as well and the MP is a new placement as of last week. On second attempt with 19g (gauge) 1" Huber needle, strong robust blood return obtained and port flushed with 10cc (cubic centimeters) of NS (normal saline). Pt felt immediate discomfort and pain with flush .... Able to aspirate dilute blood. Hospitalist NP (Nurse Practitioner) notified r/t (related to) adverse symptoms. Pt states that previous infusion was 'extremely painful' the entire time but ...was unaware ...should report it. The area surrounding the port was 'very tender all weekend' and that it hurt to lift and utilize .... R (Right-MP side) arm".

Per interview on 1/21/20 at 1:36 PM with a Registered Nurse (RN#2), s/he stated that s/he was asked to access Patient #1's port on 9/12/19 because the ER (emergency room ) nurse (RN#1) was having difficulty. S/he stated that Patient #1 had expressed that s/he had some pain while the needle was being inserted. S/he stated that s/he had gotten a blood return, flushed the port, secured the dressing, pulled back and flushed the port again and had met no resistance. S/he stated that s/he had accessed "quite a few ports". S/he stated that s/he had completed training electronically and with a chest model. S/he stated that s/he was previously the hospital's Nurse Educator and that annually there was electronic training and a skills day where nursing staff demonstrated competency regarding how to care for and use central venous accesses and administer IV medications.

Per interview on 1/22/20 at 11:10 AM with a Registered Nurse (RN#1), s/he stated that Patient #1 had arrived at the hospital for his/her iron infusion on 9/12/19. S/he stated that Patient #1 was anxious about the staff's level of experience and that s/he had taken quite a bit of time to talk with and reassure the patient. S/he stated that Patient #1 had some tenderness/sensitivity at the area of his/her port prior to any attempts at accessing and/or infusing any medication. S/he stated that s/he clarified the physician's orders, palpated the site, and attempted to access the site. S/he stated that s/he was unable to access the port and asked another nurse (RN#2) to access it. RN #2 was able to access the port; and then RN#1 administered the IV iron to the patient. S/he stated that s/he instructed Patient #1 about the signs and symptoms to be aware of, to notify the nurse with anything, and gave Patient #1 his/her call bell. S/he stated that Patient #1 rang his/her call bell when the medication had finished. RN#1 stated that when s/he flushed the port with saline and heparin the patient complained of some burning at the site. S/he stated that s/he assessed the port site for any signs or symptoms of infiltration and noted that there was no redness, change in skin temperature and/or swelling; and that s/he had reported this to the provider. S/he stated that s/he knew how to access ports, other types of central venous accesses, and administer IV medication. S/he stated that it was his/her job to make sure that all accesses were functioning properly and were "not infiltrated".

Per interview on 1/21/20 at 2:05 PM with the Emergency Department/Inpatient Nurse Manager, s/he stated that it was his/her expectation that training and competency for central venous access care/maintenance and IV medication administration was done at least yearly for all nursing staff. S/he also stated that s/he provided "squad training" that was open to all staff which reviewed different topics, policies, and procedures. S/he stated this training was not mandatory and that s/he did not keep a roster of who attended; however, there was "generally a good showing, 10-15 employees".

Per review of the training and competencies for RN #1, RN #2, and a third RN who was observed during the complaint survey, there was no evidence since 2017 that these nurses had training and/or demonstrated competency for central venous access care/maintenance and IV medication administration. Per interview on 1/22/20 at 12:08 PM with the Emergency Department/Inpatient Nurse Manager, s/he confirmed that there was "no evidence" of nursing training and/or competency for central venous access care/maintenance and IV medication administration. Per interview on 1/22/20 at 12:55 PM with the Chief Nursing Officer, s/he stated that s/he recognized that the facility "did not document well". S/he stated, "feel like the people were competent, did not document the education".