A resident with acute pyelonephritis, bacteremia, UTI, ESBL resistance, and dementia received ertapenem through a midline catheter. Surveyors found no physician orders for midline monitoring or dressing changes, and an LPN set the IV flow rate at 100 ml/hour instead of the pharmacy-directed 200 ml/hour, which would have extended the infusion beyond the intended 30 minutes. The DON acknowledged the missing midline orders and the incorrect IV administration rate.
IV dressing changes were not completed as ordered for one resident with a central line, and IV dressing change and monitoring orders were not entered for two residents receiving IV therapy. Staff could not confirm when one dressing had last been changed, and the DON confirmed the facility had no TAR or progress note documentation showing the change. For another resident with a midline IV, RNs and the unit manager confirmed the dressing change and monitoring orders were missing from the record, and an RN said the orders were missed by every nurse caring for the resident for nearly eight days.
Two residents with midline IVs had clear dressings dated after insertion that contained dried rusty brown substance on gauze underneath, and staff confirmed the dressings had not been changed since placement. Records showed no orders or documentation for IV site monitoring, dressing changes, assessments, or flushes, despite one resident receiving IV fluids and antibiotics and the other having a midline reinserted for wound infection treatment.
Improper Midline Catheter IV Medication Administration: An RN administered IV Cefepime through a resident’s midline catheter without scrubbing the needleless connector, verifying line placement, or using the push-pause flush method. The resident had cellulitis and other infections, and the DON confirmed the RN should have checked placement and used the push-pause method per policy.
A resident with cardiovascular diagnoses received a physician-ordered peripheral IV for a one-time 0.9% NS infusion for low blood pressure, but there were no MAR/TAR entries or care plan details for IV care or flushes, and a nursing assessment documented no IVs shortly before discharge. After discharge, the resident’s daughter reported that the IV remained in the resident’s arm. Staff interviews revealed that RNs relied on standing orders for IV care, did not consistently document IV site condition on skin assessments, and one RN who completed the IV therapy could not recall removing the IV and stated she documented discontinuation only if she remembered. The DON stated RNs were responsible for ongoing IV care and documentation, including documenting discontinuation, and facility policy required documentation of IV removal, which was not done.
A resident with a PICC line in the upper arm was observed with a transparent dressing that had not been changed according to the expected weekly schedule. An LPN stated that PICC dressings are supposed to be changed weekly, while another LPN indicated that the RN supervisor usually performs all PICC dressing changes but was not present. The DON confirmed that weekly PICC dressing changes are required and are the responsibility of the nurse on the cart, and acknowledged that this resident’s dressing should have been changed. There was no physician order for PICC dressing changes, despite a facility policy stating that wound care is to follow current standards of practice with physician orders documented on the Treatment Administration Record.
A resident with a Midline IV for IV antibiotics and treatment of sepsis, pneumonia, MRSA, and a complicated UTI had a transparent dressing left in place far beyond the ordered weekly change schedule. Surveyors observed the dressing still dated from the original insertion, with old dried blood present, and record review plus staff interviews confirmed the dressing remained unchanged through transfer to the hospital and readmission until survey intervention.
A resident with a midline for IV fluids had a dirty dressing with dried blood under it, and the dressing had been in place longer than the facility’s weekly change interval. The resident said no one had changed the dressing since insertion and that the IV hurt and pinched her skin. Staff, including LPNs, an RN, the ADON, and the DON, stated IV dressings for PICCs and midlines should be changed weekly and as needed, and they agreed the dressing was bloody, dirty, and needed to be changed. The record also lacked IV monitoring orders and an IV care plan.
A resident with a PICC line had a transparent dressing with gauze underneath it, and the dressing remained dated with no change noted during observations. An LPN later took a BP on the same arm directly over the PICC line, and staff interviews showed inconsistent understanding of central line dressing care and that BP should not be taken on an arm with a PICC line.
A resident was found to have a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal. Nursing staff did not document or communicate the presence of the device, and no orders were obtained until prompted by surveyors. The device remained unused, and the resident was unaware of its purpose during their stay.
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