Failure to Follow Professional Standards for IV Care and Nutritional Supplementation
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards for two residents. For one resident with a midline catheter, the facility did not perform or document required measurements of arm circumference and catheter length during dressing changes, as specified in both physician orders and facility policy. Observations and interviews confirmed that these measurements were not completed, and staff acknowledged the importance of these steps for proper catheter management. In a separate incident, another resident with a history of dysphagia and recent weight loss was not provided with a prescribed nutritional supplement (Boost VHC) during multiple observed meals, despite clear physician orders. Staff interviews revealed that the supplement was not consistently given, and the registered dietician was unaware of the omission. Facility policy required that physician orders be followed, but the supplement was not provided as ordered during the survey period.