Deficient Monitoring and Documentation of IV Therapy and PICC Line Care
Penalty
Summary
A deficiency was identified regarding the administration and monitoring of parenteral/IV fluids for several residents. For one resident with osteomyelitis, there was an increase in the Vancomycin dosage from 1500 mg to 2000 mg intravenously daily, but there was no documentation in the medical record providing the clinical rationale for this change. Although a pharmacy document indicated a low trough level as the reason for the dosage increase, this information was not accessible in the resident's medical record, and no progress note was completed by the nurse to explain the adjustment. Another resident, admitted for IV antibiotics following pneumonia and a secondary joint infection, missed three antibiotic doses (one Vancomycin and two Cefepime) while on a leave of absence (LOA) with family. The medical record did not contain documentation that the resident’s physician or infection preventionist was notified about the missed doses, nor were there progress notes outlining the next steps or physician instructions following the missed medications. A third resident, who had a PICC line for IV antibiotics, did not have documented monitoring of the external catheter length during dressing changes, as required by the facility’s standard operating procedure. Additionally, there was no documentation of arm circumference measurements or assessment of the external catheter in the treatment administration record, progress notes, care plan, or admission assessment. The facility’s policy required measurement of the external catheter length at each dressing change, but this was not completed or documented for the resident.
Plan Of Correction
Element 1 Resident #8 PICC line was discontinued prior to entrance of survey team. Resident #84 medical record was updated with rationale for the increased Vancomycin. Resident #289 physician was contacted regarding missed doses due to resident being out on LOA. Element 2 An audit was completed for residents who have PICC lines to ensure measurements of the external catheter length are documented in the TAR/MAR or in a progress note. Any concerns identified were corrected. An audit was completed for residents who have had an increase in dosage of Vancomycin to ensure rationale was documented in the medical record. Any concerns identified were corrected. An audit was completed for residents who leave the facility on LOA to ensure dosage of medications were not missed. If any medications are missed due to the resident being out of the facility, documentation of physician notification in the patient's medical record. Element 3 Director of Nursing/Designee completed re-education to licensed nurses in measuring PICC line from the insertion site to the end of the PICC line on admission and weekly with dressing changes. Director of Nursing/Designee completed education to licensed nurses in the process for when pharmacy adjusts the dose of Vancomycin via phone call or fax; the staff will adjust the order and document. Director of Nursing/Designee completed education to licensed nurses in the procedure for missed doses: the nurse will contact the physician and document in the patient's medical record. Any staff members not educated by May 20, 2025, will be educated on their next scheduled shift. Unit Managers/Designee will verify that there are no missing PICC line weekly measurements during morning meetings. Nurse Managers will review medication orders during morning meetings to ensure all increases of Vancomycin dosage have documentation of physician rationale. Nurse Managers will review medical records for any missed dosage of medications while residents are out on leave to ensure physician notification is documented in the patient's medical record. Element 4 Unit Manager/Designee will complete random weekly audits for four weeks of PICC line measurements, change in Vancomycin dosage rationalization, and missed dosage documentation. The results of findings will be submitted to the DON, who will report findings to QAPI for review and recommendations. Element 5 The Director of Nursing is responsible for maintaining compliance.