Failure to Monitor and Care Plan for New Peritoneal Catheter
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for a resident with liver cirrhosis and chronic ascites who had both a left-side thoraco-abdominal drain and a newly placed right tunneled peritoneal catheter. Upon the resident's admission and subsequent readmission, the facility did not obtain or document post-procedure care instructions for the right tunneled peritoneal catheter, as the family had taken the instructions and staff did not contact the interventional radiology department to acquire them. There were no physician orders or care plan entries specific to the care, monitoring, or drainage frequency for the new catheter, and the baseline care plan only referenced abdominal drains in general without distinguishing between the two sites. Clinical documentation, including assessments, progress notes, medication administration records, and treatment administration records, lacked any reference to the right tunneled peritoneal catheter, its care, or monitoring. The readmission assessment noted the presence of a right lower quadrant drain site covered by a surgical dressing, but did not include follow-up appointment details or specific care instructions. Additionally, a change in condition assessment inaccurately described the resident's recent hospitalization as a drain repair rather than the placement of the new catheter, and a skin evaluation prior to discharge did not acknowledge the presence of the right tunneled peritoneal catheter. Interviews with facility leadership confirmed that there was no evidence of continued monitoring, no appropriate physician orders, and no implementation of a care plan for the right tunneled peritoneal catheter. The resident was later sent to the hospital for worsening jaundice and was admitted for sepsis and a mucus plug in the bronchi. The facility's actions and omissions were not in accordance with their own policies or professional standards of nursing practice, as required by state regulations.