HospitalInspections.org

The nursing service must ensure that patients receive ongoing assessments of their needs and provide nursing staff to meet those needs. Based on interviews and record review the hospital failed to ensure there was an ongoing assessment and evaluation of 1 of 1 (Patient #1) patient's PICC line. After the patient received a PICC line, the patient was found to be laying in blood.

Findings included:

On 01/16/24 a complaint was submitted to the hospital alleging Patient #1 was left bleeding after his PICC line placement (Peripherally inserted central catheter). After reviewing the medical record with Personnel #1 on 05/15/24, it was determined there was no documentation reflecting the patient's PICC line site was assessed, monitored, or was bleeding after the line was inserted on 01/16/24.

Interviews confirmed the incident.
During an interview on 05/15/24 at 1:00 PM with Personnel #2 he said he remembered Patient #1. He had placed a PICC line in the patient on 01/16/24. When he left the patient following the placement, the patient was not bleeding. He was notified the patient was bleeding about 1-1 ½ hours after he left the hospital. He immediately returned to the hospital. He placed a pressure dressing on the PICC line site. He said the nurse should have placed a pressure dressing on the site. He said maybe the nurse didn't see the blood because the patient had covers on him. Blood had seeped under the patient. He was able to stop the bleeding.

During an interview on 05/15/24 at 1:15 PM with Personnel #3 she said nurses should monitor the PICC line site after insertion to make sure there was no bleeding. She said she called Personnel #2 after she learned Patient #1's site was bleeding. She couldn't remember who told her about the bleeding. The surveyor asked if nurses should document their findings after monitoring a PICC line site. She confirmed the findings should be documented.

During an interview on 05/15/24 at 2:00 PM with Personnel #1 she confirmed there was no documentation of monitoring, assessment or of bleeding after Patient #1's PICC line was inserted on 1/16/24.

Policy
The hospital's Central Venous Access Devices policy, with a revision date of 10/01/22 reflected, "...RN staff will be responsible for care and maintenance of all central lines..."