HospitalInspections.org

Based on document review and interview, the nurse executive failed to ensure nursing personnel followed established Central Venous Access Device policies and procedures (P&P) for 10 of 10 patient medical records (MR) (P1-P10).

Findings:

1. Review of the policy titled Central Venous Access Devices (CVAD), Number C-56-N, indicated the following:
a. CVADs include centrally inserted catheters, peripherally inserted central catheters (PICCs), and implantable ports.
b. The key components of the Central Line Post Insertion Care and Maintenance Bundle are:
* Hand Hygiene * Aseptic technique during dressing changes *Consistent care during dressing changes, tubing changes, cap changes, flushes, line accessing by providing specific procedures *Ensuring patency of the line
c. RN (registered nurse) staff will be responsible for care and maintenance of all central lines
d. Dressing changes will be done...
*Whenever the dressing becomes damp, loosened or visible soiled *TSM (transparent dressing) every 7 days *Gauze dressings every 2 days *A gauze dressing underneath a TSM dressing is considered a gauze dressing
e. Tubing changes, flushing and locking of devices will be done per policy/procedure
f. Caps will be changed once a week during dressing change...
g. The policy was approved 3/10/16 and issued 4/1/16

2. Review of the policy titled Central Venous Access Devices (CVAD), Number C56-N-2, indicated the following:
a. Administration sets, including add-on-devices, are changed at established intervals...
b. Administration Set Change Frequency by Administration Type:
i. Continuous - every 72-96 hours
ii. Intermittent - every 24 hours
iii. Intravenous fat emulsion - every 12 hours/with each container change
iv. Parenteral Nutrition - every 24 hours
c. Assessment, Site Care/Dressing Changes:
i. CVAD catheter site care and dressing changes are performed at established intervals and...as follows: *Whenever the dressing becomes damp, loosened or visible soiled *TSM (transparent dressing) every 7 days *Gauze dressings every 2 days *A gauze dressing underneath a TSM dressing is considered a gauze dressing
d. Documentation: *Performance of procedure, including type of antiseptic solution/type of dressing *Patient's response to the procedure *Instructions given to patient
e. Accessing and Deaccessing Implanted Vascular Access Ports:
i. When administering an infusion via an implanted port, the noncoring needle is replaced at least every 7 days.
ii. A sterile dressing is maintained over the access site if the implanted vascular access port remains accessed.
f. Documentation: *Appearance of port site *Performance of procedure *Noncoring needle gauge/length *Medication/solution administration *Pain management interventions *Flush/lock solution and volume * Patient education * Patient's response to the procedure
g. The policy was approved 3/10/16 and issued 4/1/16

3. Review of patient MRs indicated the following:
a. P1 was admitted to the hospital on 1/21/16 with a PAC (implanted port) in place, was administered continuous, intermittent, fat emulsion and parenteral nutrition infusion solutions throughout the course of stay and discharged 2/4/16. The MR lacked documentation of PAC dressing change procedures, at least every 7 days per P&P, that included type of antiseptic solution/type of dressing, patient's response to the procedure and instructions given to patient, lacked documentation of any tubing changes and lacked documentation of cap changes every 7 days.
b. P2 was admitted to the hospital on 11/25/15 with a PAC in place, was administered intermittent infusions and discharged on 12/9/15. The MR lacked documentation of the PAC needle being changed after 11/25/15, dressing changes per P&P with documentation of procedure including type of antiseptic solution/type of dressing, patient's response to the procedure and instructions given to patient for any dressing change or cap change every 7 days.
c. Review of P3's MR indicated P3 was admitted to the hospital on 1/27/16 with a HD (hemodialysis) catheter in place, was administered intermittent infusions and discharged on 2/29/16. The MR indicated a "permacath" was placed in the right chest on 2/4/16 at 19:40 hrs. Nursing IV Documentation dated 2/16/16 at 9:11 hrs indicated the patient had a PICC (peripherally inserted central catheter). Dialysis Treatment Records indicated CVAD dressing changes were done on 2/8/16, 2/10/16, 2/15/16 and 2/19/16 but lacked documentation of which dressing, type of solution/type of dressing, patient's response and instructions given to patient for the 2/8/16, 2/10/16 and 2/15/16 dressing changes. The Dialysis Treatment Record also indicated a dressing change was performed on 2/23/16, but lacked documentation of which dressing, type of solution/type of dressing and instructions given to patient. The MR lacked other documentation of CVAD dressing changes every 7 days per P&P with documentation of procedure including type of antiseptic solution/type of dressing, patient's response to the procedure and instructions given to patient for any dressing changes.
d. P4 was admitted to the hospital on 1/19/16 was administered intermittent and continuous infusion solutions and discharged 3/1/16. The MR indicated an existing IJ device was removed and replaced with another triple lumen IJ catheter on 1/26/16. The MR lacked documentation of CVAD dressing changes every 7 days per P&P with performance of procedures that included type of antiseptic solution/type of dressing, patient's response to the procedure and instructions given to patient for any dressing change and lacked, lacked documentation of any tubing changes and lacked documentation of cap changes every 7 days.
e. P5 was admitted to the hospital on 9/9/15 was administered intermittent and continuous infusions throughout the stay and discharged on 2/4/16. MR IV documentation indicated on 10/7/15 the patient had a Trialysis infusion catheter and on 12/7/15 a ML (midline) infusion catheter. The MR lacked documentation of Trialysis or ML dressing change procedures, at least every 7 days per P&P, that included type of antiseptic solution/type of dressing, patient's response to the procedure and instructions given to patient lacked documentation of any tubing changes and lacked documentation of cap changes every 7 days.
f. P6 was admitted to the hospital on 10/12/15 with a PICC (peripherally inserted central catheter) in place, was administered intermittent IV medications and discharged on 11/11/15. The MR lacked documentation of PICC dressing change procedures that included type of antiseptic solution/type of dressing, patient's response to the procedure and instructions given to patient. Nursing IV Documentation for 11/13/15 at 21:50 hrs, 11/14/15 at 20:32 hrs and 11/24/15 at 7:15 hrs was void of catheter type/site code, PICC Line Bundle, Justification for patient having a central line, Location, Insertion date, Phlebitis scale, Last Date Dressing Changed and Injection cap changed documentation.
g. P7 was admitted to the hospital on 6/15/16 with a PICC in place, had been administered intermittent and continuous infusions and was an in-patient at time of survey. The MR lacked documentation of PICC dressing change procedures that included type of antiseptic solution, patient's response to the procedure and instructions given to patient for any dressing change and lacked documentation of any tubing changes.
h. P8 was admitted to the hospital on 6/9/16 and was an in-patient at time of survey. The MR indicated the patient had IV push medications, fat emulsion and parenteral nutrition infusions. Nursing IV Documentation on 6/13/16 indicated the patient had a PICC in place. The MR lacked documentation of PICC dressing change procedures that included type of antiseptic solution, patient's response to the procedure and instructions given to patient for any dressing change and lacked documentation of any tubing changes.
i. P9 was admitted to the hospital on 6/15/16 and was an in-patient at time of survey. The MR indicated the patient had IV push medications and intermittent infusions. Nursing IV Documentation on 6/15/16 indicated the patient had a PICC in place. The MR lacked documentation of PICC dressing change procedures that included type of antiseptic solution, patient's response to the procedure and instructions given to patient for any dressing change and lacked documentation of any tubing changes.
j. P10 was admitted to the hospital on 1/11/16 with a PAC in place, was administered continuous, intermittent, fat emulsion and parenteral nutrition infusion solutions throughout the course of stay and discharged 1/25/16. Nursing IV Documentation dated 1/11/16 at 19:18 hrs indicated the Last Date Dressing Changed as "01/12/2016". The MR lacked documentation of PAC dressing change procedures that included type of antiseptic solution/type of dressing, patient's response to the procedure and instructions given to patient for any dressing change and lacked documentation of any tubing changes.

4. On 6/20/16 at 12:30 pm, A3, Infection Control Nurse, indicated the facility had identified inconsistencies in CVAD dressing changes and implemented a plan of action for one specified nurse to perform all scheduled dressing changes. This was implemented at the end of February 2016. At 5:30 pm, A3 indicated review of MRs since the new process did not show documentation of dressing changes per policy/procedure and that tubing change documentation was not included in the MR.