Failure to Flush IV Catheter as per Policy
Penalty
Summary
The facility failed to ensure proper flushing of an intravenous line for a resident, as required by their policy. The policy, dated November 21, 2024, mandates that midline and central line intravenous catheters be flushed to maintain patency, prevent mixing of incompatible medications, and ensure the complete administration of medication. The policy specifies using the SASH method (saline, administer medication, saline, heparin) for intermittent treatments. For Resident 10, physician's orders dated November 14, 2024, required staff to flush the peripherally inserted central catheter (PICC) with 10 ml of 0.9 percent Normal Saline every shift to maintain intravenous line patency. Despite these orders, the Medication Administration Records (MARs) for November 2024 showed that staff administered one gram of Ertapenem Sodium intravenously every day at 9:00 a.m. from November 15 through 24, 2024, without documented evidence of flushing the catheter before or after medication administration. This was confirmed in an interview with the Director of Nursing and Assistant Director of Nursing on December 18, 2024, who acknowledged the lack of documentation for flushing the IV catheter according to the facility's policy.
Plan Of Correction
1. Resident 10's intravenous (IV) flush orders, before and after medications, were clarified with the Medical Director. Resident 10 had no ill effects. 2. Residents with IV flush orders were reviewed for accuracy. Registered Nurses were educated on clarifying before and after medication administration flush orders for IVs. 3. Director of Nursing or designee will audit residents with IV orders to ensure they include flush orders for before and after medication administration weekly times four and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.