Failure to Follow IV Therapy Standards and Care Planning for Resident with UTI
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and its own policies for a resident receiving IV antibiotic therapy. Facility policies required that vascular access devices used for intermittent infusions be flushed with prescribed flushing/locking agents to maintain patency, that short peripheral IV catheter dressings be changed at least every seven days or sooner if compromised, that dressings be labeled with the date, time, and nurse’s initials, and that peripheral catheter sites be assessed before and after intermittent infusions and at least once every shift when not in use. Resident 66, who had dementia and a urinary tract infection, was readmitted from the hospital with an existing IV access line in the left antecubital area. Physician orders included meropenem 1 g IV twice daily over three hours, but there were no corresponding orders for any flushing/locking agent, IV access site changes, or dressing changes. Observations on two separate days showed the IV dressing was intact but lacked any date, and hospital records did not document when the IV site was started or when the dressing was last changed. The facility’s admission/readmission observation for this resident documented a urinary tract infection and that orders were reviewed with the physician, but it did not document the presence of the IV access site. The baseline care plan also did not include the resident’s current infection requiring enhanced barrier precautions, the IV access site, or the care required for that site. During interviews, the DON and the Regional Director of Clinical Services confirmed that there should have been orders in place for a flushing agent, IV access site changes, and dressing changes upon readmission, and that the baseline care plan should have included the infection, isolation precautions, and IV access site. These omissions resulted in care that did not follow facility policy or professional standards for managing peripheral IV therapy for this resident.
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