Failure to Obtain Physician's Order for Midline Catheter Placement and Care
Penalty
Summary
The facility failed to ensure that care provided to Resident #154 met professional standards of quality by not obtaining a physician's order for the placement and care of a Midline catheter. Resident #154, who was admitted with diagnoses including urinary tract infection, recent fall, and high blood pressure, had a Midline placed in the right upper arm as documented on 4/16/25. However, a review of the physician's orders, treatment administration record, and care plan for April 2025 did not show any documentation of a physician's order for the Midline placement or its care. Interviews with the Unit Manager and the Director of Nursing confirmed the absence of the required physician's order and care instructions for the Midline, which is contrary to the facility's policy requiring a prescriber's order for vascular access devices.