Failure to Maintain Orders and Monitoring for Resident's IV Access
Penalty
Summary
A deficiency was identified when a resident with significant medical conditions, including anoxic brain damage, tracheostomy, gastrostomy, and vertebral osteomyelitis, continued to have an intravenous (IV) access in place without current physician orders for its care and maintenance. The resident had previously been receiving IV antibiotics via a tunneled catheter, with orders for dressing changes and site monitoring that were discontinued after the antibiotic course ended. Despite the IV access remaining in place due to postponed removal appointments, there were no active orders for dressing changes, site monitoring, or catheter flushes. Observation of the resident confirmed the presence of the IV access with a dressing dated several days prior, and the Director of Nursing acknowledged that monitoring and dressing changes should have been ongoing. Review of the electronic health record revealed no documentation of current care or monitoring for the IV site. Facility policy required physician orders for IV therapy, regular site checks, and documentation, none of which were in place for this resident at the time of the survey.