Failure to Implement IV Care Orders and Documentation for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to implement physician's orders and follow current professional standards of practice for the maintenance and infection prevention of an intravenous (IV) line for a resident receiving IV therapy. The resident, who had diagnoses including immunodeficiency, benign neoplasm of the meninges, and osteonecrosis, had a physician's order for IV ceftriaxone but no accompanying orders for the care and use of IV pumps, tubing, syringes, or flushes. The electronic health record lacked documentation of IV site assessments, normal saline flushes, heparin lock flushes, monitoring for side effects, or PICC dressing changes until several days after the IV therapy began. Interviews with facility staff revealed that standard orders for IV care, such as flushing and site assessment, were not initiated upon admission, and the nurse on duty did not obtain the necessary orders from the physician. The facility's policy required the admitting nurse to review and verify standing orders with the physician, but this process was not followed, resulting in the absence of essential IV care orders and documentation. This deficiency was identified for one resident reviewed for IV therapy.