Failure to Document and Maintain IV Site per Standards of Practice
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including diabetes mellitus, dementia, urinary tract infection with an indwelling catheter, and heart failure, was observed to have an intravenous (IV) site in the left forearm with a dressing that was not dated. During a medication pass, staff could not determine how long the IV site had been in place due to the missing date, and the responsible LPN acknowledged that the site should be replaced if undated. Review of the resident's electronic medical record showed that the documentation of the IV placement lacked details such as the size of the catheter, number of attempts, and the resident's comfort during the procedure. Further review of the resident's physician orders for the relevant month revealed there was no order to change the IV site every 72 hours, as required by standards of practice. The facility's policy on catheter insertion and care indicated that administration sets and tubing should be changed at specific intervals to prevent infection, but this was not reflected in the resident's care. The Nursing Home Administrator confirmed that the expectation was for IV dressings to be dated and sites to be changed every 72 hours or sooner if indicated, but this was not followed in this instance.