Other·February 3, 2022

F 694 § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility failed to ensure the peripheral intravenous (IV, an intravenous catheter that is threaded into a peripheral vein) site was maintained and assessed as per the facility's policy and procedure (P&P) for one of two sampled residents (Resident 1). * Resident 1 had a peripheral IV inserted on the left foot which was left for seven days without a physician's order to leave the IV catheter longer than 72 hours. In addition, the facility failed to ensure the IV site was assessed for complications and patency. This failure resulted in Resident 1 developing an unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black [dead tissue]) at the IV site on the left foot. Findings: Review of the facility's P&P titled Peripheral IV Catheters (undated) showed all peripheral venous catheters and needles will be changed every 72 hours and as needed for signs and symptoms of complications. A physician's order is required to leave an IV in for longer than 72 hours. Heparin flushes must be ordered by the physician, or follow the pharmacy or facility's protocol and should include strength, amount, and frequency of flushing. Heparin flushes are intended to maintain patency by filling the IV device, to prevent blood coagulation. Some centers may elect to use saline only for flushing peripheral lines. Effectiveness of using saline for cannula patency (IV flush) needs to be recorded. The IV site will be assessed for signs of complications such as edema (swelling), redness, and moisture at the insertion site. The IV site assessment will be documented in the resident's medical record. Closed medical record review for Resident 1 was initiated on 12/7/21. Resident 1 was admitted to the facility on 11/20/21, and discharged to the acute care hospital on 11/30/21. Review of the Resident Initial Assessment dated 11/20/21, showed Resident 1 was admitted to the facility with a left arm cast with sling. The assessment showed Resident 1 did not have any skin impairment. Review of the Progress Notes dated 11/22/21 at 1914 hours, showed Resident 1's physician was notified of no venous access on the resident's upper extremities and the physician agreed to insert the peripheral IV line on the lower extremities. Review of Resident 1's Order Summary Report showed a physician's order dated 11/22/21, to insert the peripheral IV line on the resident's lower extremity. Another physician's telephone order dated 11/22/21, showed to change Resident 1's peripheral IV site as needed for pain, redness, swelling, or infiltration, with an end date of 11/24/21. Review of the IV Related Orders for November 2021 showed Resident 1 received IV hydration on 11/22 and 11/23/21. Review of the Resident Transfer and Referral Record dated 11/30/21, showed Resident 1 was transferred to the acute care hospital with a peripheral IV line on the left foot. However, there was no documentation to show the IV line was assessed for patency or for any complications from 11/22 to 11/30/21. Review of the acute care hospital's Emergency Department notes dated 11/30/21, showed Resident 1 presented with an IV on the left medial malleolus (the bump that protrudes on the inner side of the ankle). The IV catheter was "taped over the bone," was not accessible, and had to be discontinued. Upon removal, the Registered Nurse (RN) noted an unstageable pressure injury in the wound bed; until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined) over the left medial malleolus (ankle bone). The documentation showed the wound bed was noted with 76-100% slough. The wound measured 0.5 cm (length) x 0.5 cm (width) x 0.25 cm (surface area). The documentation showed the wound care team was consulted for evaluation of the unstageable pressure injury to the left medial malleolus caused by a medical device (IV catheter). On 12/7/21 at 0830 hours, a concurrent interview and closed medical record review was conducted with RN 1. RN 1 was asked how often the peripheral IV lines and dressings should be changed. RN 1 stated it should be changed every 72 hours and should be removed if there was no physician's order to keep the IV line longer than 72 hours. RN 1 was asked if she had assessed Resident 1's IV site, flushed the IV site, and checked the patency of the IV site on Resident 1's left foot. RN 1 stated she asked the night shift RN to flush and assess the IV site before discharge. When asked to show documentation Resident 1's IV site was assessed, flushed, and checked for patency,RN 1 was unable to show such documentation. RN 1 further stated the IV site should be assessed, flushed, and checked for patency every shift. On 12/7/21 at 0850 hours, a concurrent interview and closed medical record review was conducted with RN 2. RN 2 was asked if she had assessed, flushed, or checked the patency of Resident 1's IV site during Resident 1's stay in the facility. RN 2 stated she could not recall. RN 2 then stated she did assess the IV site and did not see any wound or injury. RN 2 was unable to provide documentation of the assessment. On 12/9/21 at 1145 hours, a concurrent telephone interview and closed medical record review was conducted with the Director of Nursing (DON). The DON verified Resident 1 had the IV line inserted on 11/22/21, and was transferred to the acute care hospital on 11/30/21, with the IV line still in place. When asked if Resident 1's IV site was monitored for signs and symptoms of infection or complications, the DON was unable to show any documentation the IV site had been assessed. The DON stated they could keep the IV line in if the resident was a "hard stick," but the licensed nurse should obtain an order from the physician to keep the IV line longer than 72 hours or when not in use. The DON was asked about the facility's protocol to flush the IV line when the IV line was not in use. The DON stated the IV site should be monitored and flushed with 5 ml of normal saline (a solution used to prevent IV blockage and removes any medicine left in the catheter area) to check for patency every shift. The DON was unable to show any documentation Resident 1's IV site had been monitored, flushed, or checked for patency. The above violation either jointly, separately or in any combination had a direct or immediate relationship to the resident's healthy, safety or security.