Failure to Obtain and Implement Orders for Port-a-Catheter Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care of a port-a-catheter for one resident following the placement of a new device, as indicated in the hospital discharge instructions. The resident had a port-a-cath placed on the right side of the chest, and discharge instructions 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 acknowledged 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 physician order sheets, medication administration records, and treatment administration records from June 2024 through May 2025, showed no orders for the care or maintenance of the right-sided port-a-cath. Interviews with nursing staff revealed confusion and lack of awareness regarding the presence and required care of the resident's port-a-cath. Some staff believed the port had been discontinued, while others recalled previous orders to flush the port but could not recall details or the specific location of the device. There was also no documentation of any staff communication with the physician regarding the discontinuation or ongoing care of the port. Facility leadership, including the DON and Administrator, stated that staff should be aware of the presence of a port-a-cath and that its care should be documented in the medical record. They also indicated that any conversations with physicians regarding the port's care should be documented, but acknowledged that this had not occurred. The resident's primary physician and the facility medical director both confirmed that ports should be flushed regularly to maintain patency and expected staff to obtain appropriate orders upon the resident's return from the hospital if none were provided.