Failure to Care Plan for Central Venous Access Device
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s central venous access device (port-a-catheter). The resident was admitted with multiple complex diagnoses, including high-grade papillary urothelial carcinoma status post chemoradiation, peripheral vascular disease, chronic kidney disease stage 4, COPD, respiratory failure with hypoxia, and the presence of a cardiac pacemaker, among others. The admission MDS showed the resident was moderately impaired, and the care plan initiated shortly after admission addressed impaired cognitive function and risk for abnormal bleeding due to anticoagulant/antiplatelet use. However, review of the care plan initiated on 11/22/25 revealed no evidence that the presence of a port-a-catheter was addressed. There were no interventions for site care or dressing changes, no interventions for flushing or maintenance of the line, and no monitoring for complications such as infection, occlusion, or dislodgement, and no staff guidance regarding management of the central IV access. Multiple clinical records documented the existence of the implanted port in the right upper chest, including the hospital discharge summary, nursing progress notes, and several provider progress notes by different physicians over multiple days, all confirming the presence of a port-a-catheter or central IV line. During interviews, a GNA recalled that the resident had an IV line in the right chest upon admission but did not know what type of line it was or how it was managed. A staff nurse confirmed that the resident had IV access via a port-a-catheter and stated that care related to the IV access, including dressing management, was unclear due to the absence of a care plan. The MDS nurse acknowledged that the resident had a significant clinical condition and treatment that should have been reflected in the care plan, and the Administrator stated that the care plan should address residents’ clinical needs and guide staff in delivering care.
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