Failure to Ensure Proper Physician Orders and Maintenance for Peripheral IV Administration
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for two residents by not having proper physician orders in place for the maintenance and rotation of peripheral IV sites. For one resident with diagnoses including COVID-19, myocardial infarction, and hyponatremia, the clinical record showed that IV Ceftriaxone was started for a urinary tract infection. However, there was no corresponding physician order for the IV medication or for the required site maintenance, such as rotating the access site every 96 hours. The resident’s IV site dressing was observed to be 11 days old, and the site was not rotated or removed as per protocol, with the batch order set for IV maintenance not implemented until several days after IV initiation. Another resident, diagnosed with sepsis, a right femur fracture, and chronic obstructive pulmonary disease, was started on IV Ceftriaxone for cellulitis. Similarly, there was no physician order corresponding to the medication administration record, and the batch order set for IV site maintenance was not in place when the IV was started. The IV site was not discontinued within the recommended 96-hour period, and the facility did not provide a written policy for peripheral IV site maintenance when requested. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the required batch order set, which includes parameters for site rotation, flushing, and monitoring, was not implemented at the time of IV initiation for either resident. The DNS acknowledged that the oversight resulted in IV sites remaining in place longer than recommended and that appropriate orders were not obtained for each resident started on a peripheral IV.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a PICC line for extended IV antibiotic therapy had a provider order and care plan directing that the PICC dressing be changed every seven days on the day shift. The MAR reflected this order, but the scheduled dressing change was not completed or signed off, and no nursing note documented a reason. Subsequent observation showed the PICC dressing still dated from a prior week with curled corners, confirming it had not been changed as ordered. The assigned nurse admitted not performing the dressing change, and leadership, including the DON and Nurse Practitioner, confirmed that PICC dressings are expected to be changed at least every seven days to prevent infection.
A resident with osteomyelitis and a stage 4 sacral pressure ulcer was receiving daily IV ceftriaxone via a midline in the right chest wall, but the facility failed to obtain or document physician orders for midline care and maintenance and did not follow its care plan requiring weekly dressing changes and shift-by-shift observation. Surveyors observed a transparent dressing on the midline dated over 30 days earlier, with the lower edge not fully adhered, and the resident reported that staff had not changed the dressing. The DON acknowledged that the dressing should have been changed weekly, and there was no documentation of required assessments or dressing changes, resulting in an Immediate Jeopardy citation at F694-J.
A resident admitted with multiple serious conditions, including infective endocarditis, had orders for IV antibiotics to be administered via a PICC line but no corresponding orders for PICC care, such as flushing or dressing changes. Staff, including an RN and the DON, stated that PICC care is usually done routinely and included in batch admission orders, but acknowledged that these orders were not entered for this resident, resulting in IV therapy being provided without documented PICC line maintenance orders.
A resident with dehydration was ordered 0.9% sodium chloride IV at a specified rate and volume, and the MAR reflected that these fluids were administered over several shifts, with one documented refusal. However, nursing documentation and direct observation later showed that D5NS was infusing instead of the ordered 0.9% sodium chloride, reportedly because the ordered solution was unavailable. One nurse acknowledged she did not visually verify the IV bag, tubing, fluid type, or rate against the provider’s order during her shift, and the Medical Director and DON both reported they had not been informed that a different IV solution was being used in place of the ordered fluid.
An LPN without required IV certification administered ordered IV Vancomycin to a resident with multiple complex conditions, including UTI, sepsis, CHF, kidney failure, vascular dementia, and type 2 DM with circulatory complications. The resident’s EMR and MAR showed IV Vancomycin doses given, and the MAR contained the LPN’s initials for one of the administrations. The LPN acknowledged not being certified to give IV antibiotics but confirmed having administered them, and the ADON verified that IV certification is required for LPNs to infuse IV antibiotics and that this LPN was not on the facility’s list of IV-certified LPNs.
A resident with a PICC line for long-term IV vancomycin therapy and an active MSSA infection did not receive safe, person-centered PICC care as ordered. The care plan noted the PICC but lacked specific goals, interventions, and monitoring for PICC care and IV antibiotics. After a prior PICC malfunction and replacement, staff did not document arm circumference or external catheter length. On observation, the PICC dressing was peeling, saturated with yellow drainage, and dated well beyond the facility’s 7‑day change policy and the physician’s weekly order, despite the TAR showing a recent dressing change. IV tubing from an empty antibiotic bag was unlabeled, uncapped, and hanging freely, and no emergency PICC kit was present or ordered at the bedside. The RN Unit Manager and DON confirmed failures in dressing maintenance, tubing management, catheter monitoring, availability of emergency supplies, and accurate documentation.
Failure to Follow PICC Line Dressing Change Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow a Nurse Practitioner’s order for PICC line dressing changes for a resident receiving IV antibiotic therapy. The resident was cognitively intact, had a PICC line for a 38‑day course of IV antibiotics, and had an order dated 03/20/26 for the PICC dressing to be changed every seven days on Fridays. The care plan and MDS reflected the presence of the PICC and the need for dressing changes per order. The MAR included an order to change the PICC dressing every Friday on dayshift starting 03/27/26, but the entry for 03/27/26 was left blank and not signed, and there was no progress note explaining why the dressing change was not completed. On 03/29/26, observation of the resident’s PICC site showed an intact dressing with curled corners, no redness or drainage, and a date of 03/18/26, indicating the dressing had not been changed as ordered on 03/27/26. The nurse assigned to the resident on 03/27/26 acknowledged he was supposed to change the PICC dressing per the order but did not complete the task. The ADON later confirmed that when she changed the dressing on 03/30/26, the old dressing was still dated 03/18/26 and stated she expected it to have been changed on 03/27/26. The DON stated that IV access dressings must be changed at least every seven days, with daily flushes and daily monitoring for signs of infection, and that the assigned nurse should have recognized the dressing was overdue. The Nurse Practitioner also stated she expected dressing changes every seven days and that exceeding this timeframe increases the risk of infection.
Failure to Maintain and Change Midline IV Dressing per Policy and Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate care and management of a midline peripheral venous access device in accordance with its own policy and professional standards of practice for one resident. Facility policy required staff to inspect the catheter-skin junction and surrounding area, palpate through the intact dressing for redness, tenderness, swelling, and drainage, note any pain, numbness, or tingling, and change a midline dressing weekly or if soiled, with physician orders specifying dressing type and frequency. CDC guidelines cited in the report recommend replacing transparent dressings on short-term central vascular catheter sites at least every seven days. The resident involved was admitted with osteomyelitis of the sacral/coccyx area and a stage four sacral pressure wound, was cognitively intact, and had IV access for daily IV ceftriaxone for osteomyelitis. The clinical record, including the Medication Administration Record for February and March, showed no physician orders for care and maintenance of the midline access site. The resident’s care plan identified risk for complications related to IV medication and included interventions for staff to observe the right chest wall dressing every shift and to change the dressing weekly, but these interventions were not carried out as required. Surveyor observations on two occasions on the same day showed that the resident had a midline peripheral access site in the right chest wall with a transparent dressing dated more than 30 days earlier, indicating the dressing had not been changed weekly as required. The bottom part of the dressing was not fully adhered to the skin. In an interview, the resident stated that staff had not changed the dressing. There was a lack of documentation to support that the facility had assessed the access site or changed the dressing at least every seven days and as needed, and the DON confirmed that the dressing date showed it should have been changed weekly but was not.
Removal Plan
- Upon resident return, review the resident's chart and follow physician's orders.
- Assess residents with a PICC line to assure appropriate measures for care and management of a midline peripheral venous access device are in place and ensure weekly dressing changes are properly ordered by the physician and completed.
- Review residents admitted with a PICC line to assure physician's orders include weekly dressing changes; RN Supervisor will ensure orders are in place.
- Review the policy and procedures for PICC and wound management to ensure professional standards are provided.
- Educate licensed nursing staff on the policy and procedure related to care and management of a midline peripheral venous access device and wounds.
- Educate licensed nursing staff on obtaining physician's orders when any new skin alteration is identified.
- Educate all staff scheduled for the evening shift on the policy and procedure related to care and management of a midline peripheral venous access device and wounds and on obtaining physician's orders when any new skin alteration is identified.
- Educate all staff scheduled for the night shift on the policy and procedure related to care and management of a midline peripheral venous access device and wounds and on obtaining physician's orders when any new skin alteration is identified.
- Educate all other licensed staff and providers via telephone on the policy and procedure related to care and management of a midline peripheral venous access device and wounds and on obtaining physician's orders when any new skin alteration is identified.
- Remove from the schedule any licensed staff who cannot be reached pending completion of education.
- Review new admissions/re-admissions to ensure all physicians' orders are verified; audit and report results in QAPI.
- Conduct random audits of residents with PICC/wounds to ensure dressing changes are completed as ordered; audit and report results to QAPI.
Failure to Obtain PICC Line Care Orders for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to obtain and document provider orders for the care and management of a resident’s PICC (peripherally inserted central catheter) line despite ongoing IV antibiotic therapy. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder, and had admission orders for two IV antibiotics to be administered via the PICC line two to three times daily. However, the admission orders did not include any directives for PICC line care, such as flushing, dressing changes, or other maintenance. Nursing staff, including an RN and the DON, reported that routine PICC line care (flushes, weekly dressing changes, checking for a cap, measuring the line and arm circumference) is normally performed and is supposed to be included in batch orders entered at admission, but acknowledged that these orders were not entered for this resident. This omission resulted in the resident receiving IV medications through a PICC line without corresponding written orders for line care and maintenance, as confirmed by interview and record review.
Failure to Administer Ordered IV Fluids as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to administer IV fluids according to the physician’s order for a resident receiving treatment for dehydration. The resident, cognitively intact and admitted with chronic pain, had a verbal order from the Medical Director for 0.9% sodium chloride IV solution at 80 mL/hr for a total of 2 liters. This order was transcribed onto the MAR, which showed the IV fluids as administered on multiple shifts from late February into early March, with one documented refusal on a night shift. The MAR entries indicated that the ordered sodium chloride IV fluids were being given as prescribed. On March 1, MAR documentation by nursing staff showed that instead of 0.9% sodium chloride, D5NS (5% dextrose in 0.9% sodium chloride) was infusing because the ordered 0.9% sodium chloride was reportedly unavailable. An observation that afternoon confirmed a one‑liter bag of D5NS infusing through a saline lock in the resident’s forearm, with the bag labeled only with a date and no initials. The resident reported receiving IV fluids for dehydration, stated she did not like to drink, and believed she had been receiving IV fluids all day, but was unable to identify the type of fluid. In interviews, Nurse #2 stated she received report that the IV fluids had completed during the night and that a new bag had been hung just before shift change, but she did not visually inspect the IV bag or tubing during her shift and could not confirm which fluids had been given. She acknowledged she was required to verify the fluid type, amount infused, and flow rate against the provider’s order but did not do so. The Medical Director reported he had not been informed that D5NS was administered instead of the ordered 0.9% sodium chloride and stated he expected staff to notify a provider of any medication administration issues. The DON stated she was not aware that the wrong IV fluid had been administered or that staff had documented using D5NS due to unavailability of 0.9% sodium chloride, and indicated staff were expected to administer IV fluids as ordered and to use pharmacy‑supplied, resident‑specific labeled fluids.
Uncertified LPN Administered IV Antibiotic
Penalty
Summary
The facility failed to ensure that an LPN who administered an IV antibiotic to a resident had the required IV training/certification. The resident had multiple diagnoses, including urinary tract infection, sepsis, difficulty walking, unspecified skin changes, chronic congestive heart failure, kidney failure, unspecified organism, vascular dementia, and type 2 diabetes mellitus with circulatory complications, and had a physician’s order for Vancomycin 750 mg IV every 18 hours over several days in February 2026. The resident’s EMR and MAR showed that the ordered Vancomycin IV piggyback was administered, and the MAR for one of those days contained the initials of an LPN who later stated she was not certified to give IV antibiotics, although she acknowledged she had administered some to this resident about a month prior and planned to obtain training in the future. The Assistant Director of Nursing confirmed that LPNs at the facility are required to have specific certification to infuse IV antibiotics, verified that the initials on the MAR identify the person who administered the medication, and stated that this LPN’s name did not appear on the facility’s list of LPNs certified to administer IV medications. Thus, the IV Vancomycin was infused by an LPN who lacked the required IV certification, contrary to facility expectations and practice as described by nursing leadership.
Failure to Maintain Safe PICC Line Care and IV Antibiotic Management
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, person-centered PICC line care and IV antibiotic administration for a resident receiving long-term IV therapy. The resident was admitted with a left leg fracture and active MSSA infection and had a PICC line inserted in the hospital for long-term IV antibiotics. The comprehensive care plan identified the presence of a PICC line for antibiotic therapy but did not include measurable goals, specific interventions, or monitoring related to PICC line care and IV antibiotic administration. Physician orders directed weekly PICC dressing changes on Tuesdays and as needed, and ordered IV vancomycin 1000 mg twice daily through a specified end date. Clinical documentation showed that on one occasion the PICC line was not patent, would not allow infusion of vancomycin, and had been pulled out 5 cm from the insertion site, resulting in the resident being sent to the emergency room, where the PICC was replaced. After replacement, there was no documented evidence that staff monitored arm circumference or measured and documented the external catheter length, despite the known prior complications with the PICC line. This lack of monitoring occurred even though the hospital documentation specified the new catheter length and external measurement at the skin. During an observation, the resident’s PICC dressing was found peeling at the bottom, with yellow drainage throughout most of the surface, and was dated from a prior month, indicating it had not been changed in accordance with the facility’s seven-day dressing change policy or the physician’s weekly order. The resident reported it had been a long time since the dressing was changed, and the RN Unit Manager confirmed the dressing should have been changed. At the same time, an empty antibiotic bag was observed on the IV pole connected to unlabeled IV tubing that lacked a sterile end cap and was hanging freely. No emergency PICC kit or supplies were present in the room, and there were no physician orders or documentation requiring or monitoring an emergency kit at the bedside. The Treatment Administration Record showed a dressing change documented as completed the day before, which was inconsistent with the observed condition and date on the dressing. The DON confirmed the failures related to PICC dressing maintenance, tubing management, catheter monitoring, absence of emergency supplies, and inaccurate documentation.
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