Failure to Identify and Monitor Accessed Implanted Port Leading to Sepsis
Summary
The deficiency involves the facility’s failure to identify, monitor, and provide care for an implanted venous access device (port) that remained accessed after a resident returned from multiple hospitalizations. The resident had a complex medical history including colorectal cancer, recurrent sepsis, chronic anemia requiring multiple blood transfusions, severe protein-calorie malnutrition, recurrent infections, and an implanted vascular access port placed in the left chest. Hospital records repeatedly documented the presence of this implanted port, including notes that it was accessed on several admissions. However, on each readmission to the facility (12/29/25, 01/09/26, 01/20/26, 02/20/26, and 03/12/26), there was no evidence in the facility’s admission assessments, baseline care plans, or progress notes that staff identified the presence of the implanted port. Following the resident’s hospitalization from 02/17/26 to 02/20/26 for anemia and nephrostomy tube concerns, the resident returned to the facility on 02/20/26 with the implanted venous access device still accessed with a Huber needle and covered by a dressing. Despite this, the facility’s admission assessment and baseline care plan dated 02/20/26 did not document the port or that it was accessed. Subsequent skin observations on 02/21/26 and 02/28/26, and daily skilled nursing assessments from 02/21/26 through 02/28/26 and again on 03/02/26, 03/03/26, and 03/04/26, contained no indication that staff recognized the accessed port, provided any site care, or monitored the site. Physician orders from 02/20/26 to 03/04/26 showed no orders for monitoring or care of the implanted device. The facility’s venous access policy required routine assessment and monitoring of venous access sites at least once per shift, but the DON confirmed there was no evidence in the record that the device had been identified or monitored in any way. On 03/04/26, when the resident arrived at an outside oncology infusion center for a chemotherapy appointment, an oncology RN observed that the implanted port was still accessed with a Huber needle and covered by a heavily soiled, partially intact dressing with a date that appeared to be 02/11/26, later clarified as likely 02/17/26. The oncology nurse described the resident as disheveled, unbathed, lethargic, uncomfortable, and unable to keep his head upright, and noted that the dressing edges were peeling and that there was significant concern for infection risk. The oncology nurse removed the dressing, obtained blood return from the port, and, after the resident reported feeling weak and dizzy, the oncology physician directed that the resident be sent to the ED. Hospital records from that day documented sepsis and shock, with blood cultures drawn from the implanted port growing gram-positive cocci and MRSE, and the resident was admitted to the ICU for treatment of sepsis. The DON, facility RNs, and the resident’s physician later acknowledged that the facility did not access ports, that most nurses were not trained in port use, and that the device had not been identified or monitored while the resident was in the facility, despite the port remaining accessed during that time.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident was admitted with hospital paperwork indicating a regular diet with TPN and a PICC line, but the facility did not transcribe a TPN order into the chart or document the hospital communication that TPN had been discontinued. Staff relied on verbal clarification from the hospital, while the record lacked clear TPN administration, mixture, and monitoring orders. The resident later required IV fluids and a new PICC line after low BP was noted.
IV Therapy Not Consistently Documented or Monitored: A resident with Parkinson’s Disease and acute respiratory failure had IV fluid and IV antibiotic orders, but the IV site was observed with a loose, unsecured, undated dressing and a dark red dry substance on it. Staff reported the IV was left in place after fluids were given, then restarted for more fluids, but IV insertion, removal, and restart attempts were not documented, and the resident’s chart lacked IV documentation for several days.
Unlabeled and undated peripheral IV dressing: A resident receiving IV abx for a UTI was observed with a peripheral IV in the left hand infusing medication, and the transparent dressing was unlabeled and undated. The resident’s record showed an order for ceftriaxone and a care plan for IV catheter monitoring, while facility policy required the dressing label to include the date, time, and initials. An RN and an LVN both confirmed the dressing should have been labeled and dated.
PICC care and IV documentation were not completed as ordered for a resident with a PICC placed for IV antibiotics. The admission assessment did not document key PICC details, and a clinic RN later observed a peeling dressing, an unclamped PICC, no legible dressing date, and no stat lock in use. The EMAR/ETAR did not show required connector or dressing changes on schedule, and no q12h maintenance flushes were documented after IV antibiotics stopped.
A resident with a PICC line and significant medical complexity, including bacteremia, sepsis, MS, and CHF, did not have the line properly monitored, flushed, capped, or redressed per facility policy and standards of care. The chart lacked PICC orders, care plan interventions, and documentation of site checks or dressing changes, and staff interviews confirmed uncertainty about the line’s care and documentation. When the resident arrived at the hospital, the PICC dressing was not intact, the hub was uncapped, and the line appeared to have shifted.
Failure to change a resident’s PICC dressing as ordered. A resident with osteomyelitis had a PICC line with an order for the transparent dressing to be changed on admission and weekly, but the dressing was observed clean, dry, and intact and the resident stated it had not yet been changed. The TAR showed no documentation that the dressing was changed as ordered, and the DON confirmed the lack of documented evidence.
TPN Order Not Transcribed or Documented After Admission
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids and TPN-related services for a resident admitted with a hospital discharge instruction that included a regular diet with TPN. The resident had a history of cancer, atrial fibrillation, heart failure, diabetes, and depression, and arrived with a LUA double-lumen PICC line in place. The hospital After Visit Summary included the handwritten instruction “Regular diet with TPN,” but the facility’s order summary did not contain a physician order for TPN, and the admission record did not show that the order had been transcribed into the medical record. At admission, nursing staff contacted the hospital for clarification and were told by the discharging nurse that TPN had been discontinued. That conversation was not documented in the record. The facility also did not document communication showing that the original physician order had been changed. The resident’s record showed a question mark written in front of the diet instruction, and the MDS listed IV access as blank. The facility’s own review later noted that the resident had been admitted with paperwork indicating regular diet with TPN, but there were no specific orders for TPN administration, mixture, laboratory monitoring, or initial formula in the chart. Progress notes showed that the resident remained without documented TPN orders until the issue was later revisited by the IDT. During this period, the resident had a PICC line, later had the line removed, and subsequently developed low blood pressure requiring IV fluids and then a new PICC line for normal saline infusion. Interviews with the admitting nurse, NP, DON, and Medical Director confirmed that the order clarification was not documented and that staff relied on verbal communication from the hospital without recording it in the medical record.
IV Therapy Not Consistently Documented or Monitored
Penalty
Summary
The facility failed to ensure that IV fluids were administered consistently with professional standards of practice for Resident #42, who was admitted with multiple diagnoses including Parkinson’s Disease and acute respiratory failure. The resident had physician orders for IV normal saline and IV ceftriaxone on 6/19/26, followed by another IV sodium chloride order on 6/20/26, and an order on 6/22/26 to inspect the IV catheter/site every day and night shift for signs or symptoms of infection or other complications. On 6/22/26 at 10:07 AM, the resident was observed with an IV in the right arm; the dressing had a dark red dry substance on it, the edges were loose, the IV line was not secured, and the dressing was not dated. Staff interviews and record review showed the IV was not consistently documented or monitored. LPN #1 stated the resident had received a bag of fluids and the IV was left in place in case more fluids were needed, and that the dressing should have been changed every three days and dated. The resident’s care plan did not document the IV, and the medical record lacked IV documentation from 6/19/26 through 6/21/26. The DON stated the IV was started on 6/19/26, removed after the bag of fluid, then restarted on 6/20/26 when more fluids were needed; the DON also stated there was no order for dressing changes or IV site monitoring because the original IV had been removed, and that monitoring orders were entered on 6/22/26. RN #1 stated he did not document the IV insertion on 6/20/26 and later made a late entry, and LPN #2 stated he removed the IV on 6/19/26 without documenting it and did not document the attempt to restart the IV on 6/20/26.
Unlabeled and undated peripheral IV dressing
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for one sampled resident, Resident 16, who was receiving IV antibiotic therapy for a UTI. During observation, Resident 16 was lying in bed with a peripheral IV line in the left hand infusing IV antibiotics. The IV site had minimal redness and swelling, and the transparent dressing was observed to be unlabeled and undated. The resident’s medical record showed a physician’s order for ceftriaxone sodium 2 gm IV daily for seven days, and the care plan identified the need for a peripheral IV catheter and frequent monitoring of the site for signs of complications. The facility’s policy for peripheral venous catheter insertion required the dressing label to include the date, time, and initials. During interview, an RN confirmed the dressing should have been labeled and dated, and an LVN stated the IV dressing should have been labeled with the date, time, and initials when inserted. The RN also stated the IV antibiotic infusion was stopped and a new IV line would be reinserted. The Administrator and DON were informed of the findings and acknowledged them.
PICC Care and IV Documentation Not Completed as Ordered
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for one resident with a PICC line. The resident was a Spanish-speaking male with a history of small bowel obstruction repaired surgically with colostomy placement, an abdominal abscess requiring IV antibiotics, and prior brain bleed with craniotomy, aphasia, and one-sided weakness. The hospital transfer summary documented that a PICC was inserted before discharge for IV antibiotic use, and the nursing admission evaluation noted an IV present in the left upper arm, but it did not document the venous access type, size and length of the access, arm circumference, or an observation and description of the IV site. The resident’s PICC care was not completed as ordered and was not consistently documented. A clinic RN reported that the dressing was peeling at the corners, the PICC was not clamped, there was no legible date on the dressing, and the stat lock was not in use. Facility orders required the needless connector and dressing to be changed every 7 days, but the EMAR/ETAR did not show the connector or dressing changed on the due date, and no documentation was found showing the next scheduled changes were completed. After IV antibiotics were stopped, the record also showed no maintenance flushes of the PICC every 12 hours. The DON stated that nurses had been re-educated on PICC and IV therapy, including required orders, documentation, dressing care, and proper use of connectors.
PICC Line Not Monitored, Flushed, or Redressed
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a PICC line by not monitoring the resident for complications, not assessing the PICC insertion site, not performing PICC flushes, and not providing a sterile dressing change at least every seven days. The resident had diagnoses including bacteremia, sepsis due to Serratia, multiple sclerosis, and chronic combined systolic and diastolic heart failure. The admission MDS documented intact cognition and the resident required extensive assistance with bathing, dressing, bed mobility, and transfers, and was non-ambulatory and wheelchair dependent. The resident’s care plan did not identify the PICC line and contained no related goals or interventions. The EMR lacked orders for PICC dressing changes, flushes, or site monitoring, and the TAR for the month reviewed showed no evidence that staff performed flushes, dressing changes, or site checks. The nursing admission screening documented a PICC in the right upper arm with the last dressing change on 06/01/2026, but the record contained no evidence of any further dressing change, site assessment, or flush after that date. The chart also lacked evidence that the PICC hub had been capped by staff. When the resident arrived at the hospital, Consultant GG stated the PICC hub had no cap or covering, the dressing was not intact, the line appeared to have come out a few centimeters, and there was no date or initials on the dressing to show when it had last been changed. She also stated the resident had poor hygiene and reported not bathing in 10 days. Staff interviews confirmed uncertainty about PICC orders and documentation, with nurses stating PICC lines should be capped, flushed, assessed, and dressed on a schedule, and that orders should be in the chart. The facility policy stated PICC lines were to be flushed and locked according to protocol and dressing changes were to be done weekly or if soiled, with physician orders specifying dressing type and frequency.
Failure to Change PICC Dressing as Ordered
Penalty
Summary
The facility failed to implement appropriate measures for the care and management of a PICC line for one resident with osteomyelitis. The resident was admitted with a PICC line, and the care plan directed staff to change the dressing as ordered by the physician. On May 28, 2026, the physician ordered the transparent dressing to be changed on admission and then weekly. During an observation on June 18, 2026, the resident’s PICC dressing was clean, dry, and intact, and the resident stated it had not yet been changed. Review of the Treatment Administration Records showed no documented evidence that the dressing was changed on June 10 or June 17, 2026. The DON confirmed there was no documented evidence that the dressing was changed as ordered.
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