Failure to Follow IV Line Care Policy and Physician Orders
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and physician's orders regarding intravenous (IV) line care for a resident with end stage renal disease and diabetes mellitus. The resident had IV lines in both arms, with orders to check the IV line every shift and to change the IV line, dressing, and cap every three days. Observations over several days revealed that the left arm IV and its dressing had not been changed for at least nine days, and the right arm IV dressing was dislodged, undated, and the tubing was bloodied. The resident reported pain and discomfort from the IV, stated that the IV and dressing had never been changed, and was unaware of the reason for the continued presence of the right arm IV, which was not being used for medication administration. Record reviews and staff interviews confirmed that the required assessments and dressing changes were not performed as ordered. The Assistant Director of Nursing (ADON) acknowledged that she did not know the date the IV dressing was labeled, did not change the IV line or dressing as required, and did not inform the physician about the failure to change them. The ADON was also unaware of the right arm IV's continued presence and condition, which had not been assessed or maintained. The Treatment Nurse (TN) documented the presence of both IVs but did not communicate the right arm IV to the ADON, and the Director of Nursing (DON) confirmed that the right arm IV was not monitored, increasing the risk of infection. The facility's policy required IV site care and dressing changes at established intervals or immediately if the dressing was compromised, with assessments at least every eight hours. Despite these requirements, the resident's IV sites were not properly assessed or maintained, and communication failures among staff led to the right arm IV being overlooked for an extended period. The lack of adherence to policy and physician orders resulted in the resident experiencing pain, discomfort, and increased risk of infection.