Failure to Monitor IV Placement and Tourniquet Removal by Contracted Provider
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring following IV insertion by a contracted provider for one resident. The resident was admitted with diagnoses including syncope, generalized muscle weakness, cognitive communication deficit, and expressive language disorder, and was assessed as cognitively intact but requiring maximal assistance with most ADLs. A hospital discharge summary indicated IV fluids were to be discontinued and oral intake encouraged. On admission, nursing obtained orders for lab work due to dehydration concerns, and later, at the request of the resident’s POA, the DON obtained an order for PRN IV fluids and contacted a contracted IV company to place an IV line. Documentation from the contracted company showed IV line placement was completed and signed off at a specific time, but the medical record contained no immediate post‑procedure nursing assessment to verify removal of the tourniquet or evaluate the IV site. A late entry nursing note documented that the POA was concerned about hydration and that an IV team placed an IV line; the note stated the tourniquet was not removed prior to administering IV fluids and that another nurse later observed the tourniquet still in place and removed it. A subsequent nursing note documented that an IV was placed in the left arm, IV fluids were started, and that the resident’s daughter requested assessment of the arm, which was found to be swollen with a tourniquet still on the upper arm. The tourniquet was removed, the arm was elevated, and a cold compress was applied. The facility’s self‑reported incident and investigation did not specify the exact time of IV placement, the time swelling was identified, or the duration the tourniquet remained in place, and contained conflicting statements about how long the tourniquet was left on. Interviews revealed there was an expectation that staff assess IV sites after outside companies place lines, but no defined requirement for immediate post‑placement assessment. The Administrator acknowledged that the facility could not determine the timeframe the tourniquet remained on, had no documentation of when post‑placement assessment occurred until surveyor intervention, and had not provided education or information to the contracted company related to this event. An RN reported that after the contracted company completed the IV placement, he received verbal handoff, entered the room, and removed a tourniquet he observed, and then, after the resident’s daughter raised further concern, he reentered the room and removed a second tourniquet from the upper arm, noting slight swelling and applying a cold compress. He also stated that management was not notified of the arm’s condition until his next scheduled shift, and there was no documented evidence of timely monitoring by facility staff following the IV placement.
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