§ 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.
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Observations:
Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of three residents reviewed (Residents R1, R2 and R3).
Findings include:
Review of facility policy, "Central Vascular Access Device (CVAD) Dressing Change" dated January 17, 2019, revealed that CVADs include peripherally inserted central catheters (PICC) and subclavian catheters (catheter inserted into the vein near the collar bone). Continued review revealed that dressing changes are performed 24 hours post-insertion or upon admission and at least weekly. Continued review revealed that assessment of the CVAD is performed upon admission, during dressing changes, before and after administration of intermittent infusions and at least once every shift when not in use. Further review revealed that assessment of the arm with the CVAD includes, but is not limited to, erythema (redness), drainage, swelling and change in skin temperature at site.
Review of facility policy, "Midline Dressing Changes" dated January 17, 2019, revealed, "Change midline catheter dressing 24 hours after catheter insertion, every 5 to 7 days, or if it is wet, dry, not intact or compromised in any way."
Review of facility policy, "Flushing Central Venous and Midline Catheters" dated January 17, 2019, revealed, "Midline and central line access devices (CVADs) will be flushed to maintain patency, to prevent mixing of incompatible medications and solutions, and to ensure entire dosage of solution or medication is administered into the venous system."
Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated May 9, 2024, revealed that the resident was admitted to the facility on October 25, 2023, and had diagnoses including stroke (damage to the brain from interruption of its blood supply), intracranial hemorrhage (bleeding in the brain), hydrocephalus (a build-up of fluid in the brain) and respiratory failure (not enough oxygen passes from your lungs to your blood). Continued review revealed that the resident was severely cognitively impaired.
Review of Resident R1's progress notes revealed a physician's note, dated July 9, 2024, at 3:43 p.m. which indicated that the resident had pneumonia (infection in the lungs) and prescribed intravenous (IV) antibiotics.
Continued review for Resident R1 revealed a nurses note, dated July 9, 2024, at 6:46 p.m. which indicated that a single lumen midline was placed in the resident's right upper arm so that he could receive IV therapy.
Review of Resident R1's care plan, dated initiated July 9, 2024, revealed that the resident was on IV medications. No interventions were developed for the care plan. There was no indication on the care plan that the resident had a midline, nor any interventions for the care and maintenance of the line.
Review of Resident R1's Medication Administration Records (MARs) for July 2024, revealed a physician's order, dated July 10, 2024, for Piperacillin-Sod-Tazobactam (antibiotic medication), administer 4.5 grams intravenously every eight hours for pneumonia. Continued review revealed that the resident received four doses of the medication between July 10 through 12, 2024.
Continued review of Resident R1's MARs revealed another physician's order, dated July 12, 2024, for Meropenem (antibiotic medication), administer one gram intravenously three times per day for pneumonia. Continued review revealed that the resident received 20 doses of the medication between July 12 though 19, 2024.
Further review of MARs and physician orders for Resident R1 revealed that there were no orders or documentation of any IV line care or maintenance, such as dressing changes, flushes or assessments. Review of progress notes revealed that there was no indication that the IV line was assessed, flushed or monitored each shift and/or with each infusion.
Continued review of Resident R1's progress notes revealed a physician's note, dated July 23, 2024, at 10:27 a.m. which indicated that the resident completed his course of antibiotics and noted that the IV line can be pulled (removed).
Continued review of Resident R1's progress notes revealed a nurses note, dated August 6, 2024, at 1:12 p.m. which indicated, "Resident midline removed from right upper arm per MD [physician] order." Review of physician's orders revealed that a verbal order was received from the physician on August 6, 2024, to remove Resident R1's midline.
Contiinued review of Resident R1's progress notes revealed no indication was to why the resident's midline was not removed until August 6, 2024, which was two weeks after the physician recommended that the line be removed. Further review revealed no indication that the line was maintained, flushed or assessed at any time during those two weeks.
Review of Resident R2's Quarterly MDS, dated July 26, 2024, revealed that the resident was admitted to the facility on August 11, 2023, and had diagnoses including septicemia (a life-threatening infection that occurs when bacteria enter the bloodstream), stroke, seizures (abnormal electrical activity in the brain), respiratory failure, anoxic brain damage (brain damage caused by lack of oxygen to the brain) and multiple contractures (permanent shortening of a muscle or joint) of his arms and legs. Continued review revealed that the resident was severely cognitively impaired.
Review of progress notes for Resident R2 revealed a nurses note, dated July 11, 2024, at 7:23 p.m.. which indicated that the resident was readmitted to the facility from the hospital. Continued review revealed a note, dated July 12, 2024, at 9:01 a.m. which indicated that the resident had a right chest wall double lumen PICC.
Review of Resident R2's care plan, dated initiated January 24, 2024, revealed that the resident was on antibiotic therapy due to infection. Continued review revealed that there was no indication on the care plan that the resident had a CVAD in his right chest wall, nor any interventions for the care and maintenance of the device.
Review of Resident R2's MARs for July 2024, revealed a physician's order, dated July 12, 2024, for Ertapenem (antibiotic medication), administer one gram intravenously one time a day for wound infection. Continued review revealed that the resident received five doses of the medication between July 13 through 19, 2024.
Continued review of Resident R2's MARs for July 2024, revealed a physician's order, dated July 12, 2024, for Micafungin (antibiotic medication), administer 100 milligrams intravenously one time a day for infection. Continued review revealed that the resident received six doses of the medication between July 13 through 19, 2024.
Continued review of Resident R2's MARs for July 2024, revealed a physician's order, dated July 12, 2024, for Vancomycin (antibiotic medication), administer 1500 milligrams intravenously every twelve hours for wound infection. Continued review revealed that the resident received nine doses of the medication between July 13 through 19, 2024.
Further review of Resident R2's MARs and physician orders for July 2024 revealed that there were no orders or documentation of any IV line care or maintenance, such as dressing changes, flushes or assessments. Review of progress notes revealed that there was no indication that the IV line was assessed, flushed or monitored each shift and/or with each infusion.
Review of census information for Resident R2 revealed that he was in the hospital from August 8 to August 12, 2024.
Continued review of progress notes for Resident R2 revealed a physician note, dated August 13, 2024, at 9:40 am. which indicated that the resident was hospitalized due to a urinary tract infection and that he needed to continue IV antibiotics until August 16, 2024.
Observation on August 21, 2024, at 12:10 p.m. revealed that Resident R2 had a double lumen CVAD in his right chest wall. The dressing on the CVAD was dated August 12, 2024.
Continued observation, on August 21, 2024, at 2:00 p.m. Employee E2, interim Director of Nursing, confirmed that Resident R2's CVAD dressing was dated August 12, 2024, and that it should have been changed on August 19, 2024.
Review of Resident R3's Quarterly MDS, dated July 12, 2024, revealed that the resident was admitted to the facility on April 5, 2024, and had diagnoses including cardiac arrest (when the heart stops beating), respiratory failure, bacteremia (infection in the blood) and anoxic brain damage. Continued review revealed that the resident was severely cognitively impaired.
Review of Resident R3's progress notes revealed a physician's note, dated June 24, 2024, at 1:24 p.m. which indicated that the resident had a fever. The physician recommended to obtain labs, a chest xray and start antibiotic therapy. Continued review revealed another physician's note, dated June 25, 2024, at 10:50 a.m. which indicated that nursing staff needed to follow up regarding midline and antibiotic treatment. Further review revealed another note, dated June 26, 2024, at 1:17 p.m. which indicated again that nursing staff needed to follow up regarding midline and antibiotic treatment.
Continued review of Resident R3's progress notes revealed a nurses note, date June 27, 2024, at 7:42 a.m. which indicated that the resident did not have any IV access, so the antibiotic medication was unable to be administered.
Review of consultant notes for Resident R3 revealed a note, dated June 27, 2024, which indicated that a midline catheter was inserted into the resident's right arm.
Review of Resident R3's care plan, dated initiated June 6, 2024, revealed that the resident was on antibiotic therapy due to infection. Continued review revealed that there was no indication on the care plan that the resident had a midline, nor any interventions for the care and maintenance of the line.
Review of Resident R3's MARs for June 2024, revealed physician's orders, dated June 26 and 27, 2024, for Cefepime (antibiotic medication), administer two grams intravenously two times a day for infection. Continued review revealed that the resident received three doses between June 27 and 28, 2024.
Further review of Resident R3's MARs and physician orders for June 2024 revealed that there were no orders or documentation of any IV line care or maintenance, such as dressing changes, flushes or assessments. Review of progress notes revealed that there was no indication that the IV line was assessed, flushed or monitored each shift and/or with each infusion. There was also no indication as to why the IV line and antibiotic treatment was not initiated on June 24, 2024, as recommended by the physician.
Interview on August 21, 2024, at 1:40 p.m. Employee E2, interim Director of Nursing, confirmed that IV line care was not provided in accordance with professional standards and facility policies for Resident R1, R2 and R3. Continued interview revealed that the facility was unable to verify if any of the licensed nursing staff had received IV training, that the facility has a new contract with an IV company and are in the process of setting up IV training for licensed nursing staff.
28 Pa Code 211.12(1) Nursing services
28 Pa Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 09/06/2024
F0694
Please accept this 2567 with our completed Plan of Correction for Aristacare at East Falls as our letter of assertion of substantial COMPLIANCE. Preparation and submission of this plan of correction does not constitute and admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. R1, R2 and R3 intravenous therapy has been discontinued after completion.
2. Director of Nursing/ Designee will complete facility audit for any residents receiving IV therapy to include physician order for dressing changes, orders and care plans.
3. Director of Nursing / Designee will provide education to the staff concerning intravenous therapy orders, following physician orders, and care plans.
4. Director of Nursing/ Designee will complete random weekly audits x 4 weeks and monthly thereafter x 3 months for intravenous therapy orders. Audit trends will be reported to QAPI committee for review for compliance and need for ongoing audits.
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