Failure to Obtain Physician Orders for Vascular Access Device Care and Removal
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device in a resident. Upon re-admission, the resident had a vascular access device in the left upper arm, which was observed to remain in place for eleven days without any documented physician orders for its care or discontinuance. The facility's policy required nurses to obtain and verify physician orders for such devices, including their removal, care, and maintenance, but this was not followed. Multiple observations confirmed the device remained in place, with visible brownish discoloration and a small, darkened area at the site. The resident reported not receiving any medication through the device since admission and was unaware of the reason for its continued presence. Review of the resident's medical records, including physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no orders for the device's care, maintenance, or removal during the resident's stay. Interviews with nursing staff indicated a lack of awareness regarding the device's presence and the absence of any action to obtain necessary physician orders. The nurse who changed the dressing admitted to not notifying the oncoming nurse, the DON, or the physician about the device, stating she had forgotten to do so. There was no documentation in the nursing progress notes, baseline care plan, or comprehensive care plan regarding the device, and the physician was not contacted for orders until prompted by the surveyor.
Plan Of Correction
A quality audit of current residents was conducted to ensure that no ([R]) were noted without a physician order in place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with ([R]) lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for ([R]) residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.