Failure to Monitor and Reassess Change in Condition After IV Infiltration
Penalty
Summary
A deficiency occurred when the facility failed to monitor and reassess a resident following a significant change in condition. The resident, who had chronic kidney disease stage 3, experienced an elevated potassium level, for which a physician ordered a peripheral IV catheter to be inserted. The IV was placed in the back of the resident's left hand. Subsequently, the IV infiltrated, resulting in swelling and pain in the resident's left hand and arm. Despite the visible swelling and the resident's report of pain, there was no documentation of monitoring or reassessment of the affected area in the medical record. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires monitoring and documentation of changes in condition every shift for 72 hours, but this was not done. The lack of monitoring and reassessment was directly observed and acknowledged by staff, and the facility's policy review supported the expectation for such documentation.