Failure to Obtain Physician Orders for Vascular Access Device Management
Penalty
Summary
The facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device for a resident. Upon review of the facility's policy and procedure, it was found that the policy requires nurses to obtain and/or verify physician orders for the type of solution or medication, dose, rate, length of treatment, and for the removal of such devices. However, for this particular resident, there were no physician orders documented for the discontinuance, care, or maintenance of the device, despite it being in place for an extended period without use. Observations revealed that the resident had a vascular access device in the left upper arm, which had not been used for medication administration since admission. The site was noted to have brownish discoloration and a small, darkened area in the tubing. The resident reported not knowing why the device was still in place, as she had not received any medication through it since admission. Record reviews, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), confirmed the absence of any orders related to the device's care or removal. Interviews with nursing staff indicated a lack of awareness regarding the presence and management of the device. One RN admitted she did not recall if the resident was admitted with the device in place and acknowledged that only oral medications had been administered. Another staff member who had changed the device dressing failed to notify the oncoming nurse, the DON, or the physician to obtain appropriate orders, 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 existence or management of the device. The device remained in place and unused for eleven days, with no physician order for its removal until prompted by surveyor inquiry.
Plan Of Correction
Resident #111 was removed /2026 per physician orders. A quality audit of current residents was conducted to ensure that no [R] noted without a physician order 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 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. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.