Failure to Monitor Temperature and IV Site After ECT
Penalty
Summary
The facility failed to monitor temperature and intravenous (IV) access site for a resident following electroconvulsive therapy (ECT) as required by the resident's care plan and discharge instructions. The resident, who had severe cognitive impairment and diagnoses including schizoaffective disorder, bipolar type, and catatonic schizophrenia, received ECT twice weekly. The care plan and ECT discharge instructions specified monitoring for extreme headache, nausea, vomiting, confusion, temperature greater than 100.5°F, and signs of IV site complications such as redness, swelling, drainage, or pain lasting more than 24 hours. However, the physician orders transcribed into the resident's record did not include monitoring for temperature or IV site complications after ECT, and the treatment administration record (TAR) and nurse's notes lacked documentation of these assessments on multiple occasions when ECT was administered. Interviews with nursing staff and the director of nursing confirmed that special monitoring was documented in the TAR according to provider orders, which in this case did not include temperature or IV site monitoring after ECT. The medical director stated that nurses should follow patient instructions for monitoring after ECT, including checking temperature and IV site. Despite this, the resident's temperature was only checked once during the relevant period, and there was no documentation of IV site monitoring after any of the ECT sessions. The facility's policy required the interdisciplinary team to document improvements or worsening in behavior, mood, and function, but the required monitoring for post-ECT complications was not completed or documented as ordered.