PLANO, TX- THE HEALTHCARE RESORT OF PLANO

Based on record review, interviews, and observation the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered are plan, and the resident’s goals and preferences for 2 (Resident #10, Resident 40) of 3 residents reviewed for physician order for PICC line.

The facility failed to ensure there was an order prior to placing a PICC line

The facility failed to ensure proper date of dressing changes were written on the dressing for residents #10 and #40

This failure could affect all residents at the facility by placing them at risk placing a PICC line in the wrong resident, other staff including the physician not being aware of the PICC line therefore and staff including the physician not being aware of the dressing change dates, and not providing care as required.

Findings included:

Face Sheet record review of Resident #10’s dated 02/23/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis which included Metabolic Encephalopathy- (toxic metabolic encephalopathy) is a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.

Care Plan record review of Resident #10’s dated 01/31/2023 revealed, Focus- resident is on IV Cefazolin and oral Doxycycline antibiotic therapy related to cellulitis defined as a serious bacterial infection of the skin.

Usually affects the leg and the skin appears as swollen and red and painful, Interventions- administer medication as ordered. Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor each shift for adverse reactions.

Record review of MDS (Minimum Data Set is a tool for implementing standardized assessment and for facilitating care management in nursing homes) record review of Resident #10’s dated 01/31/2023 revealed, intact cognition as indicated by a BIMS (Brief Interview for Mental Status is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) score of 14 out of 15, max assistance defined as (the physical therapist performs about 75 percent of the work during mobility and resident performs 25 percent of the work) with lower body dressing, moderate assistance with toileting hygiene and shower/bathing.

Weekly Clinical/Interdisciplinary record review for Resident #10’s revealed resident on intravenous antibiotics for Bilateral extremity cellulitis.

Order Summary record review revealed, attempted to administer IV ABT this AM. Site noted non-patient. Unable to flush. Dressing not intact. Endorsed to oncoming nurse.

Order Summary medication administration record review revealed, Use 2milligram intravenously every 8 hours for Lower extremity edema for 7 days. Patient IV site not patient, unable to flush. Oncoming nurse aware.

Order Summary medication administration record review revealed Use 2milligram intravenously every 8 hours for Lower extremity edema for 7 days.

Progress notes record review of Resident #10’s on 2/20/2023 12:04 entered by LPN revealed patient was seen by nurse practitioner .cefazolin 2milligrams Intravenously every 8 hours for 7 days. Medical administration record review of Resident #10’s on 02/20/2023 reveals cefazolin sodium injection solution reconstituted 2 milligrams (Cefazolin Sodium) was given 3x beginning on 02/22/2023 and 02/23/2023 beginning at 1400 on 02/22/2023

Physician orders record review of Resident #10’s does not reveal an order for the PICC line.

An observation and interview on 02/22/23 at 01:16 PM revealed, Resident #10 sitting in her wheelchair in her room. The resident appeared well fed, well dressed, in no immediate distress with an IV site to her upper arm. The IV dressing appeared intact, with no visible labeling. Dark blood could be observed around the site at which the catheter entered the resident’s arm. Resident #10 said she was receiving antibiotics via an IV site on her arm, and she could not remember when her dressing was last changed.

Record review of Resident #40’s Face Sheet dated 02/23/23 revealed, a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included: Extradural and subdural abscess, unspecified-defined as an abscess on the dura mater, an occasional cause of back pain in febrile patients, usually in those who inject drugs. Subdural empyema is a collection of pus between the dura mater and the underlying arachnoid mater.

Record review of Resident #40’s Care Plan 01/25/23 with an admitted [DATE] revealed, Focus-On
IV-intravenous medications related to osteomyelitis, discitis, left wrist septic arthritis and subdural abscess, left knee prosthesis, Goal- will not have any compilations related to IV. Intervention-check dressing at site daily, monitor intake and outtake, monitor/document/report to physician as needed for signs/symptoms of infection at the site, drainage, inflammation, swelling, redness, warmth. Monitor/document/report to physician as needed for signs/symptoms of infiltration at the site: Edema at the insertion site, taut or stretched skin.

Blanching or coolness of the skin, slowing or stopping of the infusion, leaking of IV fluid out of the insertion site.

Record review of Resident #40’s MDS dated [DATE] revealed, BIMS score of 12 out of 15 indicating intact cognition.

Record review of Resident #40’s Physician Orders dated 02/02/23 revealed, Cefepime (an antibiotic) 1 gm/50 ml- give 1 gram intravenously every 8hrs related to osteomyelitis of vertebra, lumbosacral region for 29 days 3 times a day.

Record review of Resident #40’s Physician’s Orders dated 02/01/23 revealed, nothing by mouth diet, Enteral feeding order, PICC line care: change PICC line dressing every 7 days. Change dressing as needed or if loose or soiled as needed.

Record review of Resident #40’s February 2023 medical administration record revealed, dressing changes occurred every 7 days as ordered.

An observation and interview on 02/21/23 at 1:00PM revealed, Resident #40 lying in bed well dressed and in no immediate distress. Resident had an IV with no visible date. Resident #40 said that he was receiving IVintravenous antibiotics and his dressing had not been changed since he readmitted to the facility (02/01/23). Date on dressing 12/08/2022

In an interview on 02/22/23 at 3:06 PM, the DON said she was not sure of the exact number of residents with PICC lines in the facility. DON stated resident’s that admit with a PICC has dressings changed weekly. DON stated the Charge nurse regardless of RN or LVN changes the PICC line dressings. DON stated reason to change PICC lines weekly for infection prevention. DON stated Infection preventionist is one who follows up to ensure PICC dressings are changed. Last PICC line dressing training has not occurred since she became employed in the last 3 weeks.