Failure to Assess and Manage Central Line for Resident
Penalty
Summary
The facility failed to provide appropriate assessment, obtain treatment orders, or ensure physician follow-up for a resident with a central venous catheter. Upon admission from an acute hospital, the resident, who had diagnoses including end stage renal disease, cirrhosis, and immunodeficiency, was noted to have a central line in the left internal jugular vein. However, the admission assessment and care plan did not identify the presence of the central line or include interventions for its care or infection prevention. Nursing progress notes documented the presence of the central line and a dialysis graft, but there was no evidence of physician notification or treatment orders for the central line, nor were there orders for monitoring, site care, or dressing changes in the medication and treatment administration records. Resident and staff interviews confirmed that the central line dressing had not been changed for an extended period, and staff were unsure of the line's purpose or management responsibility. The resident reported that the dressing appeared dirty and that staff discussed its condition, but no action was taken to address it until much later. The facility's policy required licensed nurses to notify physicians and obtain treatment orders in the absence of such orders, but this was not followed. The deficiency was identified through review of clinical records, staff and resident interviews, and facility policy.