Failure to Cover Midline Catheter Injection Ports with Swab Caps
Penalty
Summary
A deficiency was identified when a resident with a midline catheter featuring two lumen injection ports did not have a swab cap covering the ports when not in use, as required by facility policy. The resident, who had diagnoses including anemia, seizure disorder, and quadriplegia, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's care plan and active orders specified that injection ports should be covered with swab caps and changed daily or as needed after use, in accordance with infection prevention protocols. During observations, it was noted that the midline catheter's injection ports were left uncapped. Interviews with nursing staff and the DON confirmed that the ports should have been covered with swab caps to prevent infection, and that this was the facility's established practice. The facility's policy also indicated that injection caps should be changed whenever removed. The failure to follow these protocols was directly observed and acknowledged by staff.