Missed Documentation of PIV Line Flushing for Resident Receiving IV Antibiotics
Penalty
Summary
A deficiency was identified during an investigation of two complaints related to the administration of IV fluids and line care for a resident with pneumonia and a urinary tract infection. The resident was readmitted to the facility with physician's orders for antibiotic administration and for the PIV (peripheral intravenous) line to be flushed every shift by licensed nurses. Review of the resident's IV medication administration record for July revealed that documentation of PIV line flushing was missing for two specific shifts: the evening shift on 7/18 and the night shift on 7/19. During a joint review of the clinical record and interview with the DON, it was confirmed that there were two missed entries for PIV flushes, and the DON could not provide an explanation for the missing documentation. The facility's policy requires frequent monitoring of residents receiving IV fluids, including monitoring catheter patency and insertion site complications. The absence of documentation left uncertainty as to whether the PIV flushes were performed as ordered.