Failure to Follow IV Catheter Care and Removal Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for preventing intravenous (IV) catheter-related infections for two residents. For one resident, an IV was observed in place despite the last dose of IV medication being administered three days prior, and the resident reported that the IV had not been flushed since then. Review of the medical record showed the IV was inserted eleven days earlier and had not been changed or removed as ordered, contrary to the facility's policy requiring peripheral IV sites to be changed every 96 hours. The registered nurse confirmed that the IV should have been removed and that the site had not been changed as required. For another resident, an IV site was present in the left upper arm, and the resident stated that no treatment or dressing change had occurred since admission. The resident also reported providing a physician's order to discontinue the IV to a nurse, but there was no documented evidence of a physician order for care or removal of the IV in the medical record. Nursing staff were unaware of the presence of the IV, and the facility was unable to provide documentation of appropriate orders or care for the IV site. The facility's policy requires prompt removal of IV catheters that are no longer essential and mandates that peripheral catheters be changed every 96 hours.