Failure to Identify and Document Peripheral IV on Readmission Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice by not accurately performing a head-to-toe readmission assessment and not identifying a peripheral IV catheter on a resident’s chest for several days. The resident, an older female with atrial fibrillation, type 2 diabetes mellitus, GERD, open wounds on the right lower leg and left buttocks, and muscle weakness, was originally admitted and later readmitted with hospital documentation that included an order for IV potassium chloride with a central line recommendation. On readmission, the admission MDS and baseline care plan did not reflect that the resident was receiving IV medications, and the skin assessment documented existing skin or wound issues but did not identify any IV on the chest area. The charge nurse who completed the readmission head-to-toe assessment stated she was not aware of an IV and would have documented it if she had seen it, acknowledging that if an IV was not noted on a skin assessment it could get infected. The peripheral IV catheter on the resident’s left breast was not discovered until a family member found it and notified staff on a later date, at which time it was removed by nursing staff, who documented that the catheter was intact and the resident reported no pain. Interviews with another LVN confirmed that a regular peripheral IV catheter was present and appeared normal, and that a proper head-to-toe assessment should have identified and documented such a device. The DON stated that if a resident had an IV, it should have been noted on the readmission skin assessment and that the facility’s usual practice would be to notify the provider and obtain orders for IV care. Facility policies on skin integrity and charting required timely and complete assessment and documentation of all services, treatments, and changes in condition, including devices and procedures, but the presence of the IV catheter on the resident’s chest was not assessed or documented from readmission until it was discovered by the family member.
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