Failure to Follow IV Therapy Standards and Orders for Two Residents
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for two residents receiving IV therapy. For one resident, a midline catheter was inserted in the left upper arm for IV fluids, but the transparent dressing over the insertion site was observed to be lifting at the edges, with dried blood visible on gauze beneath the dressing. The dressing was dated nine days prior and had not been changed as required by both physician orders and facility policy, which specify dressing changes every 5-7 days or sooner if compromised, and every 48 hours if gauze is present. Staff interviews confirmed the dressing should have been changed, and the resident reported it had not been changed since insertion. Another resident had a midline catheter inserted in error after staff misinterpreted medication orders, believing IV access was needed for antibiotic administration. The resident received all doses of the prescribed medication intramuscularly, as originally intended, and the midline was removed the following day after the mistake was identified. Documentation and staff interviews revealed that the midline was not used for medication administration, and the error was due to a misunderstanding of the medication route. The advanced practice provider confirmed that no order was given for IV administration or midline insertion. Facility policy requires a provider order and written consent for midline or PICC insertion, and specifies dressing change intervals to prevent infection. In both cases, the facility did not follow its own policies or professional standards, resulting in improper catheter care and an unnecessary invasive procedure.