F0684

D

Failure to Follow Orders and Standards for Implanted Port Use and Care

Lebanon, Missouri Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain, clarify, and follow physician orders and standards of practice for the use and care of an implanted port used to administer IV meropenem to a resident. The resident had a history of cancer with a port in the right upper chest, chronic kidney disease, vascular implants and grafts, altered mental status, chronic autoimmune liver disease, urinary retention, and a UTI. The care plan noted the presence of the port and the goal that the resident have no issues from the implanted device. The discharge MDS documented mild cognitive impairment, dependence on others for most ADLs, an indwelling catheter, and the indication for and use of an antibiotic. The facility lacked a policy or procedure pertaining to the use of a port for treatments or medications.

Physician orders dated early in November directed that meropenem be given IV every eight hours for a UTI, and on 11/04 a physician order was obtained to access the port for IV therapy and to access the port monthly and flush with 10 cc normal saline, then de‑access. However, there was no documentation of any orders or follow‑up regarding port site dressing changes. On 11/05, an order was written to access the port once for IV antibiotic therapy and then de‑access once treatment was complete, again without any documented orders for dressing changes. Nursing notes showed that on 11/05 an RN accessed the port using a Huber needle with sterile technique and the resident initially tolerated the procedure, but later that day the resident complained of pinpoint pain at the port site with flushing and no blood return was noted. The RN adjusted the needle without success and then de‑accessed the port due to continued pain and contacted the physician for further instruction.

The resident was transferred to the hospital later on 11/05 at the family’s insistence for possible sepsis and was readmitted two days later with meropenem therapy reinstated and continued IV antibiotic infusions documented through the remainder of the month. Orders dated 11/07 and 11/12 continued IV meropenem, including a dose reduction to 500 mg twice daily for one more week, but again there was no documentation of any orders or follow‑up regarding port dressing change frequency. The eMAR showed a one‑time order to de‑access the port after the final antibiotic dose, but staff documented this as “Not administered: on hold” when the antibiotic course was extended and did not enter a new scheduled de‑access time. There was no documentation that the port was ever de‑accessed after the final antibiotic dose was administered. Interviews with LPNs, RNs, the DON, the Administrator, and the physician confirmed that LPNs were not permitted to access or de‑access ports, that staff believed port dressings should be changed at least weekly or every 72 hours, that the facility had no policy on port use, and that staff should have performed routine dressing changes and followed the order to de‑access the port after the last antibiotic dose. The physician stated that nursing staff should obtain and clarify all orders regarding treatments and dressing changes.