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.
A resident with osteomyelitis, cellulitis, a stage 4 sacral pressure ulcer, paraplegia, and a PICC line was observed receiving IV vancomycin from a bag that lacked a proper label, showing only a date and RN initials. The bag did not include the resident’s name, medication dose, frequency, or route, despite an active order for vancomycin 1 g IV every 8 hours. The RN reported he had just hung the bag, discarded the original label, and knew the bag should have been labeled with full medication information. The DON confirmed the expectation that nurses ensure IV medication containers are correctly labeled and consistent with facility policy requiring verification of the container’s label against the prescriber’s order.
A resident with multiple medical conditions, including diabetes and dehydration, was found with a peripheral IV lock covered by a transparent dressing that was not dated or initialed, contrary to facility policy and standard nursing practice. Nursing staff and the DON confirmed that the dressing should have been labeled to track placement and changes, but documentation was lacking and the responsible nurse could not recall recent IV administration training.
A resident with a PICC line did not have their dressing changed within the required 7-day interval as ordered by the physician and facility policy. Staff interviews confirmed that only RNs could perform the dressing change, but the overdue change was not identified until the survey. The lapse was acknowledged by clinical leadership, who recognized the importance of timely dressing changes to prevent infection.
A resident with a PICC line for IV medications had a transparent dressing that remained in place beyond the ordered weekly change interval, with no documentation of the scheduled dressing change and no recorded refusal. The dressing was observed to be peeling and dirty on the surface, and an LVN acknowledged knowing the dressing should be changed weekly and PRN but reported not having training on PICC line dressings. In a separate observation, an LVN administering IV antibiotic via the PICC line donned gloves and a gown before hand hygiene, changed gloves without washing hands, and completed the infusion and left the room without performing hand hygiene, later admitting she forgot. Leadership interviews confirmed expectations for weekly and PRN PICC dressing changes and proper hand hygiene, and facility policies addressed central line care and hand washing, but requested training records were not provided.
A resident with a PICC line for IV antibiotics did not have her dressing changed as ordered, with the dressing remaining in place beyond the required interval. Nursing staff cited workload and communication lapses as reasons for missing the scheduled dressing change, and the infection control preventionist and DON were unaware of the overdue dressing until it was identified during the survey.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account