Champlain Valley Physicians Hospital Medical Center SNF

Based on medical record review and staff interview during a complaint investigation (#NY00106970), the facility did not ensure that a resident was provided care and services to attain or maintain the highest practicable physical well-being. Specifically, for 1 ( Resident #1)of 2 residents reviewed with a Peripherally Inserted Central Catheter (PICC) the facility did not monitor the insertion site of the newly placed central line for ten shifts. The area became painful, swollen, and red, and an ultrasound revealed a deep vein thrombosis (DVT-blood clot). Additionally, a Registered Nurse assessment did not take place for fourteen hours after the arm was reported as bruised and the physician was not notified for another three hours. This resulted in no actual harm but had the potential for more than minimal harm that is not immediate jeapordy. This is evidenced by:

Resident #1
The resident was admitted to the facility on 9/14/11 diagnosed with pneumonia, diabetes and congestive heart failure. The Minimum Data Set dated 9/26/11 assessed the resident had no long or short term memory impairment.

The facility Policy and Procedure titled Central Venous Catheter last revised on 10/15/09 documented that central line site assessments will be preformed and documented at least once per shift by the unit based RN and all signs of infection, swelling, drainage, inflammation or pain will be reported promptly to the physician.

The facility form titled "Intravenous Therapy" documented on 9/27/11 at 4:40 pm, the resident had a PICC inserted in the right upper arm.

The physicians orders dated 9/27/11 documented that the PICC dressing should be changed 24 hours after placement.

Nurse's Note dated 9/27/11 at 4:40 pm documented that the PICC was placed in the resident's right upper arm.

The 24 Hour Report dated 9/29/11 documented the resident's condition report for the 11:00 pm - 7:00 am shift noted a large bruised area at the PICC site.

Nurse's note dated 9/30/11 at 7:00 am signed by LPN #1 documented that the PICC site is noted to have a large bruise and the Intravenous Team (IVT) and charge Registered Nurse (RN) was notified.

A nurse's note dated 9/30/11 at 9:00 pm signed by RN #3 documented that the site around the PICC is bruised, swollen, warm to the touch and the resident reports that it is painful and that the charge nurse was made aware.

Nurse's note, written by an RN and dated 10/1/11 at 12:10 am documented that the PICC site is swollen, hot to the touch and the physician was consulted and ordered the PICC removed and an ultrasound of the area in the morning to rule out a blood clot.

The Ultrasound Report dated 10/1/11 documented a deep vein thrombosis (DVT, a blood clot) in the right axillary vein.

The 24 Hour Report dated 10/1/11 on the 7:00 am - 3:00 pm shift documented that Resident #1 was positive for DVT, and Lovenox (a blood thinner) was ordered by the physician to be administered for the next five days.

During an interview on 10/13/11 at 11:30 am, the Director of Nursing (DON) stated that on 10/1/11 she began an investigation after the resident was diagnosed with a DVT at the PICC site. The DON stated that the facility policy and physician orders directed that once a PICC is inserted, the dressing should be changed twenty-four hours after insertion and then each shift a RN should assess the site, write a nurse's note regarding the assessment and report any signs or symptoms of infection to the physician immediately. The DON stated that through her investigation, it was determined that the dressing to the site was not changed 24 hours after insertion and that she didn't have any evidence that the dressing had been changed at all while the PICC was inserted in the resident's right arm from 9/27/11 - 10/1/11. The DON further stated that PICC site was not assessed by an RN each shift as required and when bruising to the area was noted on 9/30/11 by a Licensed Practical Nurse (LPN) who documented that the charge nurse and the IVT was notified however there is no evidence that the notifications were made. The DON stated that the site was not assessed by a RN until 9:00 pm and the physician was not notified until 10/1/11 at 12:10 am. The DON stated the she identified that the Assistant Director of Nursing (ADON) was responsible for changing the resident's dressing and had not done so. The DON stated that she had interviewed all of the RNs involved and although they were aware of the policy to assess the PICC site each shift, the assessments were not done because they each thought someone else was doing the assessment. The DON stated that the Interdisciplinary Team meets each morning and reviews the 24 hour report, however, nothing was done as a result of the 9/30/11 11:00 pm - 7:00 am entry and stated, "we should have done something, I don't know why we didn't, but we missed it."

During an interview on 10/13/11 at 2:20 pm, the ADON stated that she is one of three RNs in the facility trained to change a PICC dressing. The ADON stated that PICC dressings are primarily her responsibility, but assumed that one of the other RNs would change the dressing. When asked if she communicated with another trained RN to request that they complete the dressing change, the ADON stated that she had not, and that she should have communicated with the other RNs if she expected them to change the dressing.

During an interview on 10/13/11 at 2:50 pm, RN #1 stated that she was unaware that the resident had a PICC and therefore she had not assessed the resident. RN #1 stated that RNs usually become aware of PICCs from the 24 hour report, by the Medication Administration Record (MAR) or in morning report.

During an interview on 10/13/11 at 4:20 pm, RN #2 stated that it is the charge nurse's responsibility to assess residents with PICC's. RN #2 stated that she was the charge nurse on 9/28/11 during the 3:00 pm - 11:00 pm shift and did not assess the resident's PICC site. RN #2 stated that she assumed because there was another RN assigned to the resident's wing, that RN would have done the assessment. RN #2 stated "we all know the policy, but we made assumptions that someone else was doing it."

During an interview on 10/13/11 at 4:50 pm, RN #3 stated that she usually works the 3:00 pm to 11:00 pm shift and is one of the RNs trained to change PICC dressings. RN #3 stated that the ADON usually does all of the dressing changes but on occasion has requested that RN #3 do a dressing change. RN #3 stated that she was not asked by the ADON to perform the dressing change and that she was not responsible for the dressing change. RN #3 stated that residents with a PICC need to be assessed each shift by an RN however, she is only reponsible to assess the resident's on her assignment. RN #3 stated that Resident #1 was on her assignment and she noticed that the PICC site was bruised, swollen, warm to the touch and that resident reported that it was painful. RN #3 stated that she notified RN#1 who was the charge nurse on 9/30/11.

10 NYCRR 415.12