Resident Discharged Home with Midline Catheter Left In Place
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safe and orderly discharge of a resident who was sent home with a midline intravenous (IV) catheter still in place, despite no ongoing medical need for the device. The resident, who had moderate cognitive impairment and was admitted with diagnoses including dysphagia and hyponatremia, had previously received IV fluids via the midline catheter for hyponatremia. The discharge summary did not indicate any devices or orders requiring IV access upon discharge. However, the resident was discharged with the midline catheter still inserted in her arm. The responsible party discovered the catheter upon arrival home and contacted the facility. Interviews with staff revealed that the discharge was rushed, and there was a lack of recall regarding the education provided to the resident and her responsible party about the catheter. The unit manager and DON confirmed that the midline catheter should have been removed prior to discharge, and the medical director acknowledged this was an oversight by nursing staff. The interdisciplinary team had discussed discharge needs, but the removal of the midline catheter was not completed as required.