Failure to Maintain and Document Central Line Care per Standards and Orders
Penalty
Summary
The facility failed to provide care and services according to standards of practice and the plan of care for three residents who had central lines or similar devices. For one resident, a central line was present in the right upper arm for medication administration, but the dressing was undated, contrary to physician orders and facility policy requiring weekly changes and dating. The assigned RN confirmed the omission and acknowledged the importance of dating the dressing to prevent complications. The Director of Nursing (DON) also confirmed that dressings should always be dated. Another resident had a line in the left upper arm for medication administration, with physician orders specifying weekly dressing changes and monitoring for signs of infection. The dressing was found to be undated and loose, with the edges lifting from the skin. The resident could not recall when the dressing was last changed. An RN later wrote a date on the dressing without changing it, and the DON acknowledged that the dressing should have been changed, not just dated, as the duration it had been in place was unknown. Facility policy required labeling dressings with initials and date at the time of application. A third resident had a line placed in the left arm, but there were no physician orders for monitoring or maintenance of the line, nor documentation in the medical or treatment administration records indicating that the site had been monitored or maintained. The dressing was undated initially, and staff could not locate orders for care or removal of the line. The DON confirmed that there should have been physician orders for monitoring, 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 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 and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central Care. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with Central 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 appropriate physicians orders were in place; and that were appropriately dated and were being appropriately maintained. All other residents were found to have appropriately maintained site and appropriate orders in place. On an, 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 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.