Ftag of the Week – F694 Parenteral/IV Fluids (Pt. 2)

This week on the CMSCG Blog, CMSCG Consultant Mary Quinn continues our discussion about the regulatory requirements for F694 Parenteral/IV Fluids. If you missed Part 1, you can check that out here. Next, we’ll review what you need to think about regarding IV therapy, including best practices.

Before we get started, here’s an actual survey citation, which although it was a low scope and severity, packs a punch from the perspective of all the potential areas of concern for a resident with a PICC line.

---

Recertification Survey Citation – F694 S/S: D

A facility was cited for failing to ensure that a resident received appropriate care to maintain a Peripherally Inserted Central Catheter (PICC) consistent with professional standards of practice and update the care plan for a resident with a PICC. Review of the resident’s medical record identified that a resident had been admitted to the facility with diagnoses which included acute osteomyelitis to the left ankle and foot, sepsis and Type 2 DM. It was documented on the MDS that the resident was receiving IV medications, and corresponding orders were found for the meds.

On further review, there were no orders found to flush the PICC line or change the PICC line dressing until several days after admission. Once the order for changing the dressing was put into place, there was no evidence on the MAR that the dressing change was signed for as completed for a month after it was ordered. The surveyor observed a sealed envelope in the resident’s paper chart, which stated on the outside that it included PICC information. The LPN told the surveyor the envelope should have been opened to confirm the measurements, and that when a resident had a PICC line on admission, orders should be written for flushes, assessing the PICC line insertion site, changing the dressing on admission and then weekly. The resident’s PICC line had been inserted prior to admission, nearly a month prior. She stated that there were no orders to flush the PICC line and that there was no order for PICC line dressing changes. She also confirmed that antibiotics were not added to the resident’s care plan until several days after admission, resulting in the care plan not being updated when the antibiotics were started or for care of a resident with a PICC line.

---

Physician Orders for IV Therapy

MD orders for IV therapy should include:

• The solution type, administration route, frequency, and infusion rate
• The type of catheter to be used should be addressed. This may be designated in many ways based on CDC terminology and estimates of risks. Appendix PP provides a lengthy list of catheter designations should you wish to review it.

Other orders to consider include the frequency of tubing and dressing changes, solution/amount and frequency of flushes as well as routine monitoring of insertion sites. While some facilities include some of these as routine facility practices by entering orders and scheduling documentation, validation of completion must be evident on the MAR/TAR.

Preparation

Typically, facilities receive IV fluids/IV medications from their pharmacy vendor. If parenteral fluids are maintained in the facility, watch for these concerns:

• A system is needed to monitor expiration dates. Facilities often store a large number of parenteral fluids or maintain stock in varied locations.  Responsibility needs to be assigned to rotate stock and check unit medication room storage to ensure that expired supplies are not left on the unit.
• Labeling of the IV fluid bag is recommended to indicate the resident name, any additives to the fluid, date and time fluid was hung. Bags received from the pharmacy are labeled, if fluids are pulled from facility stock for use, staff need to add a label and often do not.  At the bedside, it is not quite clear how the nurses are monitoring fluids administered per orders if the nurse is looking at a bag without a label that addresses flow rate, time hung, etc.
• Additives are placed into the parenteral fluids by facility staff – often contradicting facility policy.

Insertion

Only those nurses with validation of training/competencies in their files should be permitted to insert IV catheters. When reading this regulation, you’ll see the word “competency” all over it – this is extremely important for resident safety. Here’s some best practices to be aware of:

• Dating of tubing and dressing is recommended so that tubing changes can be completed following facility policy.
• A progress note should be entered indicating the type/size of catheter, insertion site and resident response to the treatment. If fluids are initiated, the type/flow rate should be addressed.
• A system should be in place to monitor the contents of any IV start boxes as expired items are frequently observed. Unless the facility has a high rate of IV therapy, it may be wise to limit the access and storage of supplies to one area.

How often do you change the site of a peripheral line?

Many facilities indicate that the insertion site is changed every three days, but often if fluids are running well and there is no evidence of infection or infiltration, the catheter remains in situ. A note indicating the rationale for leaving the catheter is not often entered but should be. Remember that your policy needs to address such a situation and you should have evidence of education being provided on the nurse’s responsibility for decision making related to such a situation.

Administration

Some dressings and flushes must be done by RNs (i.e. PICC lines) and issues in these areas have been identified and frequently cited during survey. We routinely find these issues on mock surveys, so pay attention to these key areas where issues can be identified:

• Watch that the procedures are being done and signed for by an RN. At times, a supervisor may be called to the unit to perform the task, but documentation is not entered. If there is an omission or the LPN signs the MAR, this could trigger an issue.
• PICC line dressing changes should be a routine competency for all RNs who carry out this responsibility.
• Monitoring of intake is always recommended when parenteral fluids are ordered; It can’t be assumed that the ordered rate is what is being administered. Remember what I said earlier about IV bag labels?

---

In the final part of our Ftag of the Week for F694, we’ll review maintenance and discontinuation of IV meds, prevention of infection and discuss important competencies for your staff.