Failure to Document and Monitor IV Line Care and Orders
Penalty
Summary
The facility failed to provide necessary care and services related to the administration and monitoring of intravenous (IV) lines for four residents. For two residents with peripherally inserted central catheters (PICC lines), baseline external catheter length and arm circumference measurements were not obtained or documented upon admission, as required for proper monitoring. In one case, a resident with a midline catheter did not have arm circumference and external catheter length measured on admission or during dressing changes, despite physician orders specifying these requirements. Documentation of these measurements was also missing from the medical records and IV medication administration records. Additionally, a resident with a peripheral intravenous (PIV) line did not have the site labeled with the date, time, and nurse's initials, and there was no physician's order for the PIV, contrary to facility policy and standard practice. Observations confirmed the absence of labeling and orders, and interviews with nursing staff verified that these steps had not been completed. The lack of documentation and assessment could delay the identification of IV catheter-related complications, as noted in the findings. Medical record reviews and staff interviews consistently revealed that required assessments, documentation, and care planning for IV lines were not performed according to facility policy and physician orders. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and other nursing staff acknowledged these deficiencies during interviews and record reviews. The failures were observed across multiple residents and types of IV access, including PICC lines, midlines, and PIVs.