Failure to Meet Professional Standards in IV Care, Medication Administration, and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in several areas, as evidenced by direct observations, interviews, and record reviews. For one resident receiving intravenous (IV) medication, the facility did not follow its own policies regarding IV site and tubing management. The resident had a peripheral IV device with undated and frayed dressings, and the IV tubing was not labeled with the date, time, or nurse initials. The IV site dressing was discolored, peeling, and not changed as required, and the resident reported having to hold the IV in place due to leakage. Additionally, there was confusion among staff regarding the type of IV device in place, with physician orders incorrectly indicating a PICC line when only a peripheral IV was present. Infection control practices were not followed, as the IV tubing end was not capped when not in use. The facility also failed to ensure medications were administered according to physician orders and established parameters for multiple residents. One resident received insulin injections outside of the specified blood sugar parameters on numerous occasions, and staff did not notify the provider when medication was held or administered outside of these parameters. Another resident was given oxycodone for pain ratings below the ordered threshold, with multiple documented instances of administration for pain scores less than 7, contrary to the physician's order. Staff interviews confirmed a lack of awareness and adherence to these medication administration parameters. In addition, the facility did not ensure the use of pressure-relieving devices as ordered. One resident with an order for an alternating pressure mattress (APM) was observed to have a standard mattress in place during multiple observations, despite staff documentation indicating the APM was checked and functioning. Staff confirmed the APM had been removed, but documentation continued to reflect its presence and use. Another resident received blood pressure medication outside of the ordered parameters for pulse and systolic blood pressure, with several doses administered when vital signs were below the specified thresholds.