Failure to Develop and Implement Care Plans for PICC Line Management and Physician-Ordered Services
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the use of PICC lines for two residents who were admitted with these devices for IV antibiotic administration. Record reviews showed that neither resident had a care plan problem or approaches documented for the management of their PICC lines, as confirmed by the MDS Director. One resident had a PICC line in the left arm, while the other had a PICC line initially in the left jugular vein, later replaced in the right upper inner arm. Both residents' care plans lacked documentation regarding the use and management of these lines for IV antibiotics. Additionally, the facility failed to administer IV antibiotics as ordered for one resident, with medication administration records missing documentation for specific doses. The resident reported not receiving the antibiotics as prescribed, and the DON confirmed the missed doses. Another resident did not receive restorative nursing services as ordered by the physician, with staff interviews revealing that the resident was not placed on the restorative schedule, resulting in the omission of required care. These failures were confirmed through staff interviews and record reviews.