Failure to Coordinate Specialist Care and Adhere to PICC Line Dressing Protocols
Penalty
Summary
The facility failed to coordinate appropriate care and follow physician orders for two residents with significant medical needs. One resident with chronic liver disease and Hepatitis C did not have services coordinated for specialist care or regular monitoring as ordered by the physician. Despite multiple progress notes indicating the need for hepatology consults and regular monitoring of liver enzymes and viral load, there was no evidence that the resident had seen a hepatologist or had relevant labs drawn since 2021. Facility staff, including the nurse and Director of Nursing, were unable to provide documentation of recent specialist visits or lab results, and only initiated new orders for labs and consults after the survey began. Another resident with a peripherally inserted central catheter (PICC) line did not have the dressing changed according to physician orders and facility policy. The resident was observed with a PICC line dressing that had not been changed for 13 days, despite an order for weekly changes and a policy requiring transparent dressings to be changed every 5-7 days. The resident could not recall the last dressing change, and the Director of Nursing confirmed the required frequency for dressing changes to prevent infection, but the order and policy were not followed.