Failure to Monitor and Maintain IV Sites and Dressings
Penalty
Summary
The facility failed to properly monitor and maintain intravenous (IV) sites and change heplock dressings for two residents, as required by facility policy. For one resident with a history of vancomycin-resistant enterococci (VRE) and diabetes mellitus, observations revealed a peripheral IV site with a visibly soiled, blood-stained dressing and dried blood on the tape. Multiple staff interviews confirmed that the IV site was not clean or well secured, and the dressing should have been changed due to visible soiling. Record reviews showed that there was no physician's order for IV site monitoring or dressing changes, and no documentation of IV site assessment or care in the medical record for several days. The resident's care plan also contained incorrect information, listing a PICC line instead of a peripheral IV, and lacked interventions for IV site monitoring. For the second resident, who had diagnoses including sepsis, pneumonia, and COPD, the facility did not have a physician's order for IV site monitoring or discontinuation of the IV site when it was no longer in use. Progress notes lacked documentation of IV site monitoring, and staff interviews revealed that the IV site was not assessed or monitored after IV medications were changed to oral. The resident was left with an unused peripheral IV line, and staff failed to obtain an order for monitoring or removal. The care plan did not address IV site care, and there was no documentation of assessment or intervention for the IV site during the relevant period. Facility policy required that IV dressings be changed if soiled or compromised and that peripheral IV sites be assessed at least every four hours, with more frequent checks for residents with cognitive impairment. The policy also required documentation of dressing changes and any complications. These requirements were not met for either resident, as evidenced by the lack of monitoring, documentation, and appropriate care of the IV sites.