Lincolnshire Health & Rehab: IV Safety Failures - IN
Resident D arrived at Lincolnshire Health & Rehabilitation Center on August 3 with a peripheral IV line that the hospital had not removed. The 75-year-old patient had moderate cognitive impairment and recent heart surgery, according to inspection records.
Staff documented the resident's condition but missed the IV entirely on admission paperwork. The nursing assessment indicated no IV was present, despite visible bruising from multiple insertion attempts.
A nurse's note from 12:40 p.m. on August 3 recorded "multiple areas of small bruising related to IV insertion" but did not specify whether the IV access remained in place. Another note the following evening at 9:49 p.m. again documented the bruising without indicating the line's status.
The IV wasn't discovered until August 5, when a physician noted during rounds that the resident "had a peripheral IV line from the hospital that the hospital did not remove." The doctor ordered its removal the next day.
Staff finally pulled the IV on August 6 at 3:22 p.m. A nurse documented that "the hospital stated it was to come out there" and noted the family had been notified of the removal.
The resident had been living with the forgotten IV line for three full days.
During a November 24 interview, the Director of Nursing acknowledged the oversight. She told inspectors the IV "should have documented as being present" on the admission assessment.
Facility policy required IV sites to be checked at least every shift for signs of infection, infiltration, or other complications. Records show no such assessments occurred while the line remained in the resident's arm.
The resident's medical history complicated the situation. She had undergone aortocoronary bypass surgery and managed type 2 diabetes. Her moderate cognitive impairment meant she likely couldn't advocate for herself or alert staff to problems with the IV site.
Hospital discharge summaries contained no documentation about the IV access, creating confusion about whether it should remain or be removed. The resident had been transferred from the hospital with multiple medical needs requiring careful monitoring.
The bruising documented by nurses suggested the hospital had made several attempts to establish IV access before the resident's transfer. Multiple insertion sites increase infection risk and can cause significant discomfort, particularly for elderly patients with fragile skin.
Federal regulations require nursing homes to ensure safe administration and monitoring of IV fluids and access devices. Facilities must assess all medical devices on admission and provide appropriate care throughout a resident's stay.
The oversight lasted until a physician specifically noted the line during routine rounds. Without that documentation, staff might have continued missing the IV during daily care.
The resident was eventually discharged back to the hospital due to "draining and discomfort to her surgical area." She requested the transfer for evaluation of complications related to her recent heart surgery.
Inspectors classified the violation as causing minimal harm or potential for actual harm. However, unmonitored IV sites can develop serious complications including infection, infiltration of fluids into surrounding tissue, and blood clots.
The case highlights communication gaps between hospitals and nursing homes during patient transfers. Critical medical information, including the presence of IV lines and other devices, must be clearly documented and communicated to receiving facilities.
Staff at Lincolnshire failed to conduct the basic assessment that would have identified the IV line on admission. The resident spent three days with an unmonitored medical device that required regular evaluation for complications.
The facility's own policy required shift-by-shift monitoring of IV sites. Records show this monitoring never occurred because staff didn't know the line existed.
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.
Resident D arrived at Lincolnshire Health & Rehabilitation Center on August 3 with a peripheral IV line that the hospital had not removed.
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.