Failure to Follow Standards for Vascular Access Device Care and Documentation
Penalty
Summary
Surveyors identified that the facility failed to provide care and services according to professional standards and physician orders for three residents with vascular access devices. For one resident, a vascular access dressing was observed to be undated, contrary to the physician's order requiring weekly changes and dating of the dressing. The assigned RN confirmed the omission and acknowledged the importance of dating to prevent infection and complications. The Director of Nursing (DON) also confirmed that dressings should always be dated. Another resident was found with a vascular access dressing that was undated and loose, with the edges lifting from the skin. The resident could not recall when the dressing was last changed. A nurse later wrote a date on the existing dressing without changing it, despite the dressing being loose and undated. The DON confirmed that the dressing should have been changed, not just dated, and that the facility protocol required dating upon insertion and changing every Tuesday. A third resident had a vascular access device placed, but there were no physician orders for monitoring or maintenance, and no documentation in the medical or treatment administration records to indicate that the site had been monitored or maintained. The dressing was initially undated and later dated without evidence of proper monitoring or maintenance. The DON confirmed that there should have been physician orders for care, maintenance, and removal, and acknowledged that without such orders, nurses would not be prompted to check or document the site.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: Resident #106 and #466 were immediately changed on . On a physician's order was obtained to remove Resident #520's, . No adverse consequences were identified at that time. On an in-service for all licensed nurses was initiated by the Staff Development Coordinator which addressed Central Care changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with Central and/or have the potential to be affected by this deficient practice. On a facility-wide audit was conducted for all residents with Central and/or to ensure that accurate and were appropriate physicians' orders were in place; and that appropriately dated and were being appropriately maintained. All other residents were found to have appropriately maintained site and appropriate orders in place. On , an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and C) What measures will be put in place or what system change will be made to ensure this will not recur: On , an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and Unit Managers, or designee will audit admission/readmission orders for any resident with a Central and/or to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters. maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and. Unit Managers, or designee will audit admission/readmission orders for any resident with a Central and/or to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters. F 694