Failure to Follow Physician Orders for IV Site Care
Penalty
Summary
The facility failed to provide treatment and services in accordance with physician orders and professional standards for a resident who required intravenous (IV) site care. The resident was admitted with multiple infections, including staphylococcal arthritis, methicillin susceptible staphylococcus aureus infection, cellulitis, and a cutaneous abscess. A physician order specified that all central line, PICC, and midline transparent dressings should be changed using sterile technique upon admission, every seven days, and as needed, with additional instructions for changing injection caps. The Medication Administration Record (MAR) indicated that the dressing change was documented as completed by a registered nurse on a specific date. However, during an observation, the IV site dressing was found to be dated prior to the resident's admission and had not been changed according to the physician's order. The dressing was identified as originating from the discharging hospital, and staff confirmed that it had not been replaced since admission. The Assistant Director of Nursing acknowledged that the order required the dressing to be changed every seven days and as needed, and that the MAR reflected a dressing change that had not actually occurred. Facility policy requires accurate implementation of physician orders, but in this instance, the order for IV site care was not followed.