Failure to Cap IV Line as per Standard Practice
Penalty
Summary
The facility failed to provide adequate treatment and care for an intravenous catheter (IV) line in accordance with professional standards of practice for one resident. The deficiency was identified through observations, clinical record reviews, and interviews with the resident and staff. The standard nursing practice guidelines, as outlined in a peer-reviewed journal, emphasize the importance of capping intravenous tubing and disinfecting intravenous ports to reduce the risk of infection. Specifically, the guidelines state that the exposed end of IV tubing used for intermittent infusions should be covered with a sterile cap between uses, and the port should be disinfected before connecting tubing or a syringe. Resident R220, who was diagnosed with Type II Diabetes, high blood pressure, neuropathy, and a nonhealing diabetic foot ulcer with osteomyelitis, required IV antibiotics. During an interview and observation, the resident noted that while in the hospital, orange caps were used on the end of the IV line, but the facility did not use them. The hospital records indicated that a PICC Single Lumen was placed, and the line was documented as capped. However, an interview with the Unit Manager confirmed that the IV line should be capped when not in use, indicating a failure to adhere to the standard practice at the facility.
Plan Of Correction
1. Resident R220 was assessed to ensure there were no adverse effects from this alleged behavior. Adequate treatment and care for the intravenous catheter (IV) line were provided in accordance with professional standards of practice. 2. Residents with a catheter will be assessed to ensure they had no adverse effects. 3. Staff will be educated on the components of this regulation with an emphasis on the proper administration and monitoring of parenteral/IV fluids. 4. Residents with a catheter will be audited to ensure they had no adverse effects 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.