Failure to Maintain Infection Control for Accessed Port-a-Catheter
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program for the care and maintenance of an accessed central venous device (Port-a-catheter) for one resident. The resident was admitted with high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and COPD, and had documented impaired cognitive function and moderate cognitive impairment on the MDS. Facility policy for central venous catheters required dressing changes on admission, weekly, and as needed; assessment of the insertion site; use of aseptic technique during dressing changes; routine flushing protocols; and regular needleless connector changes. Record review showed that, despite multiple provider notes documenting the presence of a Port-a-catheter on the right upper chest, there were no physician orders on admission for port dressing changes, flush protocols, or site maintenance. Staff interviews and observations further demonstrated that the accessed port was not properly maintained. A GNA reported that the resident had a dressing with an IV line to the right chest upon admission and that the dressing remained unchanged while the GNA provided showers, with no instructions given regarding IV site care or bathing precautions. A staff nurse recalled seeing the resident with a Port-a-catheter and Huber needle in place with the dressing not changed weeks after admission. The NP stated they were notified weeks after admission that the port remained accessed with no dressing changes performed. The DON confirmed that the facility did not maintain IV access or perform dressing changes and acknowledged the resident was at high risk for infection, and the Administrator reported that the oncology provider indicated the port-a-catheter was not maintained appropriately and that the lumen remained in place.
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