Failure to Obtain and Implement Orders for Port-a-Cath Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care of a resident's right-sided chest port-a-cath following hospital discharge instructions. The resident had a port-a-cath placed on the right side, as documented in the hospital discharge instructions, which specified that the port should be flushed and checked as directed by a healthcare provider, typically every few weeks. However, there was no documentation that staff reviewed or acted upon these instructions, nor was there evidence of communication with a physician to clarify or obtain orders for the care of the new port. Review of the resident's medical records, including the physician order sheets, medication administration records, treatment administration records, and injectable administration history from June 2024 through May 2025, showed no orders for the care or maintenance of the right-sided chest port-a-cath. Interviews with nursing staff revealed a lack of awareness regarding the presence and required care of the port, with some staff believing the port had been discontinued and others recalling that orders for flushing had been removed without clear documentation or rationale. The Director of Nursing and the Administrator both stated that staff should be aware of the presence of such devices and that any communication with physicians regarding their care should be documented, but acknowledged that this had not occurred. Physicians interviewed confirmed that port-a-caths should be flushed regularly to maintain patency and that staff should have sought clarification or orders for care upon the resident's return from the hospital. Despite the presence of the port-a-cath, as observed during the survey, and the hospital's instructions, the facility did not ensure that professional standards of quality were met in managing the resident's device, resulting in a deficiency related to the lack of appropriate physician orders and documentation for port-a-cath care.