HospitalInspections.org

Based on document review and interview, the facility failed to ensure that nursing personnel followed established policy / procedures for PICC procedure consents for 1 of 5 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of policy / procedure H-PC 02-005, Informed Consent, indicated the following:
"Procedure:
b. Registered nurses who are certified in the placement of PICC lines are responsible for obtaining informed consent for this procedure using a "PICC Line Insertion Informed Consent" form. Informed consent is obtained after PICC insertion is ordered by a physician or AHP with order writing authority."
This policy / procedure was last reviewed / revised on 04/2013.

2. Review of patient #1's MR indicated that a peripherally inserted central catheter (PICC) was inserted on 01-14-14 at 1315 hours. Review of patient #1's MR lacked documentation of a PICC Line Insertion Informed Consent form was completed.

3. On 03-05-14 at 0945 hours, staff #40 confirmed that patient #1's MR lacked documentation of a PICC Line Insertion Informed Consent form for 01-14-14.