Failure to Follow Professional Standards for Catheter Care and Skin Assessments
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident, who had diagnoses including acute osteomyelitis and cellulitis, there were medical orders to flush a Peripherally Inserted Central Catheter (PICC) and a Midline catheter with normal saline before and after medication administration and at regular intervals for maintenance. Review of the Treatment Administration Record (TAR) revealed multiple blank entries on specific dates, indicating that the required flushing was not performed or not documented. Both the RN Supervisor and the Director of Nursing confirmed that if the procedure was not documented, it was considered not done, and that failure to flush the lines could compromise the patency of the intravenous access. For another resident, who was severely cognitively impaired and dependent for activities of daily living, there was a failure to perform and document weekly skin assessments as required by facility policy. The resident reported having a sore, and observation confirmed the resident was in bed. Interviews with the DON and the treatment nurse revealed that the last documented skin assessment was shortly after the resident's readmission, with no subsequent weekly assessments found in the records. The treatment nurse acknowledged the importance of regular skin assessments and was unable to provide documentation of ongoing monitoring for the resident's skin condition. These deficiencies were identified through interviews, record reviews, and observations, and were confirmed by facility staff. The lack of adherence to medical orders for catheter care and the absence of required skin assessments represented failures to provide care in accordance with professional standards and facility policy.
Plan Of Correction
F684: Quality of Care CORRECTIVE ACTION On 3/27/2025, review of Resident 27 MAR regarding IV flushing showed that flushing is rendered by RN before and after IV medication administration per MD's order. On 3/19/2025 and 3/25/2025, Treatment Nurse with the Nurse Practitioner assessed the skin of Resident 49, and the skin is improving with no complications noted. OTHER RESIDENTS AFFECTED IDENTIFICATION All residents with IV orders were reviewed on 3/10/2025, and no other residents were affected by the deficient practice identified. On 3/27/2025, all residents with skin conditions were reviewed for appropriate assessment and documentation. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, in-service was provided by the DON to Licensed Nurses regarding the importance of flushing pre- and post-medication administration per MD's order for prevention of complications such as clotting and maintaining patency of the access site. On 3/25/2025, in-service was provided by the DON/Designee to Licensed Nurses regarding the importance of weekly skin assessments for residents with skin conditions. DON, ADON, RN Supervisor/Designee will monitor three times weekly the IV MAR to ensure flushing before and after medication administration is rendered per MD's order and is documented promptly in the IV MAR. OTHER RESIDENTS AFFECTED IDENTIFICATION All residents with IV orders were reviewed on 3/10/2025, and no other residents were affected by the deficient practice identified. On 3/27/2025, all residents with skin conditions were reviewed for appropriate assessment and documentation. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, in-service was provided by the DON to Licensed Nurses regarding the importance of flushing pre- and post-medication administration per MD's order for prevention of complications such as clotting and maintaining patency of the access site. On 3/25/2025, in-service was provided by the DON/Designee to Licensed Nurses regarding the importance of weekly skin assessments for residents with skin conditions. DON, ADON, RN Supervisor/Designee will monitor three times weekly the IV MAR to ensure flushing before and after medication administration is rendered per MD's order and is documented promptly in the IV MAR. MEASURES AND SYSTEMIC CHANGES (CONTINUED) DON/Wound IDT, during a weekly wound meeting, will conduct an audit ensuring all residents with skin conditions have skin assessments completed and documented on residents' medical records. MONITORING PERFORMANCE ADON/RN Supervisor will conduct weekly monitoring for four weeks, then monthly thereafter, of IV flushing and skin assessments until 100% compliance is obtained. These reports will be submitted to the QAA committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations. MEASURES AND SYSTEMIC CHANGES (CONTINUED) DON/Wound IDT, during a weekly wound meeting, will conduct an audit ensuring all residents with skin conditions have skin assessments completed and documented on residents' medical records. MONITORING PERFORMANCE ADON/RN Supervisor will do weekly monitoring for four weeks, then monthly thereafter, of IV flushing and skin assessments until 100% compliance is obtained. These reports will be submitted to the QAA committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations.