Lincolnshire Health & Rehab: Care Protocol Failures - IN
The resident arrived at Lincolnshire Health & Rehabilitation Center on August 3 with multiple diagnoses including heart bypass surgery, atherosclerotic heart disease, and type 2 diabetes. She also had moderate cognitive impairment according to her Medicare assessment.
Nobody documented the IV line on her admission assessment.
The hospital's discharge summary contained no documentation about an IV access site. But a nurse's note from 12:40 p.m. on admission day indicated the resident had "multiple areas of small bruising related to IV insertion." The note didn't specify whether an IV access was still present.
The next evening, another nurse documented the same bruising pattern. Again, no mention of whether an IV line remained in place.
Two days later, at 2:36 a.m. on August 5, a physician's progress note revealed the truth: "resident had a peripheral IV line from the hospital that the hospital did not remove."
The IV finally came out on August 6, three days after admission, following a physician's order. A nurse's note that afternoon stated the hospital "did not remove" the peripheral IV line and "it was to come out there." The family was notified after removal.
Federal regulations require IV access sites to be checked at least every shift for signs of infection, infiltration, or other complications. The facility's own policy mandated the same monitoring standards.
Instead, nursing staff documented bruising from IV insertion twice without acknowledging an active IV line remained in the resident's arm.
The Director of Nursing admitted during the November inspection that the IV was "an oversight on the admission assessment and it should have documented as being present."
This wasn't a brief oversight. The resident lived with an unmonitored IV line for 72 hours while staff noted related bruising but failed to assess the access site itself.
The resident's medical complexity made proper IV monitoring especially critical. Her recent heart bypass surgery, diabetes, and cognitive impairment created multiple risk factors for complications from an unassessed intravenous line.
Hospital discharge protocols typically require receiving facilities to assume responsibility for all medical devices and treatments upon admission. The hospital's failure to remove the IV line didn't excuse the nursing home's failure to assess and document it.
The resident was eventually discharged back to the hospital due to "draining and discomfort to her surgical area" and her own request for evaluation. Whether the unmonitored IV line contributed to her complications remains unclear from the available records.
Federal inspectors found the facility failed to ensure safe administration of IV fluids, citing minimal harm or potential for actual harm. The violation stemmed from both the failure to assess the IV site upon admission and the delayed removal of the unnecessary line.
Proper IV site assessment requires checking for redness, swelling, pain, or discharge that could indicate infection or infiltration. When IV fluid leaks into surrounding tissue, it can cause tissue damage, nerve injury, or serious complications requiring surgical intervention.
The facility's PICC line maintenance policy, current at the time of inspection, clearly outlined requirements for shift-by-shift IV site monitoring. Staff violated their own protocols by documenting bruising without assessing the active IV access.
The case illustrates gaps in communication between hospitals and nursing homes during patient transfers. Critical medical information about active treatments and devices can be lost during transitions, putting vulnerable residents at risk.
The resident's moderate cognitive impairment may have prevented her from advocating for proper IV care or reporting discomfort from the unmonitored access site.
Three days of inadequate IV monitoring violated federal standards designed to prevent serious complications from intravenous access. The resident's complex medical conditions and cognitive limitations made vigilant nursing oversight especially important.
She deserved better than an "oversight" that left a hospital IV line unassessed and undocumented for three days while she recovered from heart surgery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lincolnshire Health & Rehabilitation Center from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LINCOLNSHIRE HEALTH & REHABILITATION CENTER in MERRILLVILLE, IN was cited for violations during a health inspection on November 24, 2025.
She also had moderate cognitive impairment according to her Medicare assessment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.