Failure to Obtain Physician's Order and Document Care for Unused Line
Penalty
Summary
A resident had a line in place in the left upper arm for eleven days without a current physician's order for its discontinuance or for its care and maintenance. Multiple observations confirmed the line remained in place and was not in use, with the site showing brownish discoloration and a small, darkened area noted in the tubing. The physician's orders for the resident only included two oral medications, with no order for the line during the facility stay. Staff who identified the line did not notify the oncoming nurse, the DON, or the resident's physician to obtain appropriate orders for removal or care, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the identification or existence of the line. The physician's order to remove the line was only obtained after surveyor inquiry.