Incomplete Documentation of IV Removal
Penalty
Summary
A deficiency occurred when the facility failed to maintain a complete and accurate medical record for a resident who was admitted with diagnoses including right knee effusion and syncope. The resident had a physician order to discontinue an intravenous (IV) line in the right arm, dated the day after admission. Progress notes indicated that the resident refused IV removal three times during one shift, and a subsequent skin assessment note stated that the IV had been removed. However, there was no documentation specifying the date, time, or details of the IV removal procedure in the resident's medical record. After discharge, a home health care admission assessment found the resident still had the IV in place, contrary to the facility's discharge documentation. The home care nurse, upon discovering the IV, was instructed by the primary care provider to remove it. The facility's Director of Nursing confirmed that there was no documentation beyond the initial notes regarding the IV's removal, and acknowledged that the expected documentation—such as date, time, resident tolerance, location, reason for removal, complications, and communication—was missing, as required by facility policy.