PICC line orders and dressing care not documented: A resident receiving IV cefazolin through a PICC line had no physician orders for line flushes or dressing changes, and the dressing had no date on it when observed. Staff stated PICC lines should be flushed each shift and dressings changed weekly and as needed, but the orders were missing from the chart.
Improper Syringe Size Used for Midline Heparin Flush: A resident receiving IV therapy for cellulitis, COPD, hypertensive heart disease, and hyperlipidemia had orders for midline SASH flushing and IV antibiotics. An LVN was observed flushing the midline and using Heparin lock flush in a 5 ml syringe, while another RN later used a 10 ml syringe. The DON and staff acknowledged that a 10 ml syringe should be used for PICC, midline, or central line flushing, consistent with facility policy.
A resident with a PICC line, diabetes, obesity, atrial fibrillation, and CHF had no documented PICC-related care plan interventions, and the PICC dressing was found stained, loosening, and dated well beyond the weekly change schedule. Although the MAR showed the dressing change as completed, staff interviews confirmed it was overdue and should have been changed sooner, with the DON acknowledging it was late and that loose or soiled dressings require more frequent attention.
PICC Dressing Not Changed as Ordered: A resident with chronic osteomyelitis was receiving IV piperacillin tazobactam through a PICC line, but the clear dressing remained dated from the hospital stay and no PICC dressing changes were documented in the MAR/TAR. The resident stated the dressing had not been changed since returning to the facility. Staff gave inconsistent answers about PICC care, while the DON said PICC dressings were to be changed every 7 days and that an order set should have been entered on admission.
Overdue PICC dressing change: A resident with a PICC line, IV meds, and active infection-related diagnoses had a dressing that remained dated with an old change date during repeated observations. Staff, including the charge nurse, ADON, and DON, confirmed the dressing was supposed to be changed every 7 days per MD order and facility policy, and one nurse later confirmed it was changed late.
A resident with dementia, COPD, heart failure, and hypoxic respiratory failure received IV Invanz through a midline catheter, but the chart lacked physician orders for dressing changes, flushing, and monitoring for infection or infiltration. Staff observed the midline dressing dated several days earlier, and RN, ADON, DON, and NP interviews confirmed the absence of orders and that the dressing should have been changed on a routine schedule.
A resident with dehydration, AKI, and hypokalemia had an IV left in the L hand after IV fluids were held, but the site was not flushed as expected and remained in place despite the MD’s verbal direction to remove it. The resident reported tenderness, and surveyors observed redness, dried blood, and discoloration under the dressing. Staff interviews confirmed the IV should have been checked daily, flushed when not running, and removed when no longer needed, but this did not occur.
A resident with encephalopathy, cellulitis, UTI, pressure ulcers, and poor nutritional status had a midline IV catheter placed for NS infusion and then ordered to be flushed q12h when not in use. MAR/TAR entries showed ordered flushes were performed by RNs until an agency LVN documented a flush, after which subsequent nursing notes indicated the midline was no longer present, with no clear record of when or how it was removed. Staff interviews revealed that no practitioner order for discontinuation could be located, and there was no documentation of the removal procedure, catheter integrity, or insertion-site assessment, despite facility policy and leadership expectations that a practitioner’s order and full documentation accompany any midline removal.
A resident with a PICC line for IV antibiotics had no physician orders for PICC maintenance, saline flushes, or dressing changes, and the care plan did not include goals or interventions for PICC use and maintenance. Staff stated they were flushing the line and changing the dressing, but these tasks were not ordered on the MAR or TAR, and the DON acknowledged the PICC care had not been care planned.
A resident receiving IV Cefepime via a midline catheter did not have the IV antibiotic bag labeled with the start date/time or nurse initials, and the IV tubing was not dated, contrary to facility IV therapy policy requiring all IV tubing to be labeled with date, time, and initials and changed at specified intervals. The resident’s active care plan lacked focus areas or interventions related to IV therapy. The LVN who administered the medication acknowledged forgetting to date and initial the IV medication and tubing despite prior in-servicing, and the DON confirmed that nurses were expected to label IV medications and tubing during every antibiotic administration, noting the risk of infection and medication error.
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