Inadequate IV Catheter Care for a Resident
Penalty
Summary
The facility failed to provide adequate treatment and care for a peripherally inserted catheter for a resident, identified as Resident R118, in accordance with professional standards of practice. The facility's policy on Intravenous (IV) Therapy requires registered nurses and licensed practical nurses to inspect IV sites at least every shift and maintain a clean, dry, and intact dressing over the insertion site. However, during an observation, it was noted that Resident R118's IV access site on the right wrist was not labeled with a date or time, the dressing was lifting, and there was noticeable dried blood around the insertion site. Resident R118 was admitted with diagnoses of congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. The resident had a physician's order for cefepime to be administered intravenously every eight hours for seven days. During an interview, a registered nurse confirmed the deficiencies in the dressing and acknowledged that the facility failed to provide adequate care for the catheter. This incident was a violation of the facility's policy and professional standards of practice.
Plan Of Correction
R118 has been discharged. On the day of the findings, residents with IVs were assessed to ensure dressing sites were labeled with a date and time, and that all dressings were intact without any signs or symptoms of complications. All RNs and LPNs will be educated by the Director of Nursing and/or designee that when an IV is in place, the dressing must be labeled appropriately with a date and time, and that all dressings should be inspected at least once a shift to ensure the dressing is intact and without any signs or symptoms of complications. The Director of Nursing and/or designee will audit all residents with an IV in place to ensure that the dressing is labeled appropriately with a date and time, and that all dressings are being inspected at least once a shift to ensure the dressing is intact and without any signs or symptoms of complications. Audits will be completed weekly for 4 weeks, then monthly for 2 months, or until substantial compliance is achieved. Results will be reviewed at the Quarterly QAA meetings.