Failure to Follow Professional Standards for Central Line and Wound Care Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in two key areas: management of a central vascular access device (CVAD) for one resident and processing and following physician orders for wound care for another resident. For the resident with a peripherally inserted central catheter (PICC) line, the facility's own guidance required documentation of external catheter length and upper arm circumference upon admission and during dressing changes, as well as the use of a securement device to prevent migration. However, the admission assessment did not include these measurements, and during a dressing change, the nurse moved and rotated the PICC line multiple times without a securement device in place. The external catheter length was found to have increased from six to nine centimeters, indicating migration, but IV medication continued to be infused through the line despite this finding and without provider notification, contrary to facility policy and professional standards. For the second resident, who was readmitted with a right below-the-knee amputation and a necrotic fourth toe on the left foot, the hospital transfer orders specified a dressing change every other day with betadine application and placement of gauze between the affected toes. Upon review, these orders were not processed or initiated by nursing staff, and the resident did not have a dressing or gauze in place for the necrotic toe. Nursing staff were only monitoring the toe daily and had not reviewed or implemented the wound care orders from the hospital. The omission was confirmed by both the nurse responsible for the admission assessment and the regional clinical director, who acknowledged that the transfer orders were missed and not followed. These failures resulted in residents not receiving care in accordance with professional standards and physician orders. The lack of proper documentation, assessment, and adherence to protocols for central line management and wound care placed residents at risk for improper medication delivery and delays in treatment, as evidenced by the continued use of a migrated PICC line and the absence of prescribed wound care interventions.