Failure to Document PIV Catheter Placement and Removal
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple diagnoses, including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure. Upon admission, the resident had a right antecubital (AC) peripheral intravenous (PIV) catheter in place, as documented in the admission evaluation. However, subsequent reviews of the resident's progress notes revealed inconsistencies and missing documentation regarding the removal and placement of PIV catheters. Specifically, there was no record indicating when and why the initial right AC PIV catheter was removed, nor was there documentation of when a new left forearm PIV catheter was placed. Interviews with facility staff, including an LVN and the DON, confirmed the absence of required documentation related to PIV catheter procedures. The facility's own policy required detailed recording of catheter insertion and removal, including date, time, site, and condition of the IV site, as well as notification of the physician in case of complications. The lack of documentation was acknowledged by staff and had the potential to result in inaccurate medical interventions for the resident.