Failure to Provide TPN Results in Hospitalization
Penalty
Summary
A facility failed to provide necessary care and services for a resident who required Total Parenteral Nutrition (TPN) following transfer from a hospital. The resident, with a history of pancreaticobiliary cancer and recent paraoesophageal hernia surgery, was dependent on TPN for nutritional support. Upon arrival, the TPN was not available at the facility, and the staff initiated intravenous dextrose as a temporary measure per provider orders. The TPN was delivered the following day, but staff were unable to administer it due to incompatible tubing and equipment supplied by the pharmacy. Multiple staff members, including the admission nurse, LPN, and RN, identified the issue with the TPN supplies and communicated with the provider and nursing management. Despite repeated notifications to the nurse practitioner and continued attempts to resolve the equipment incompatibility, the resident did not receive the ordered TPN. The resident expressed increasing weakness and frustration, ultimately requesting to return to the hospital. Laboratory records confirmed a significant decline in the resident's potassium and magnesium levels, and the resident required hospitalization for dehydration and electrolyte replacement. Interviews with staff indicated a lack of clarity regarding responsibility for ordering TPN prior to admission and agreement among nursing leadership that the resident should have been sent back to the hospital sooner when the facility was unable to provide the required care.
Plan Of Correction
F684 Quality Of Care Severity Level D Compliance Date 4/30/2025 Element 1: What Corrective action(s) will be taken: Resident 502 no longer resides in the facility. Element 2: How Facility will identify other residents having a potential to be affected by the practice and what corrective action will be taken: All residents have a potential to be affected by the practice. Current residents residing in the facility were accessed by the licensed nurses to ensure that residents with changes in condition needs were being met on 04/17/2025. All residents identified as at risk for change in condition have been assessed by a licensed nurse. Element 3: What Measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur: The quality assurance team reviewed the policy for Notification of Changes and deemed it appropriate on 04/17/2025. On this date, 4/30/2025 or before their next scheduled shift, we will educate nurses on the Notification of Change Policy with a focus on the following: If a resident is admitted to the facility and is to receive TPN, the nurse is to ensure the order had been received, reviewed, and signed by the physician and faxed to pharmacy to be received in time for the resident admission. When a delay in order implementation is identified, the resident will be assessed for changes in conditions and provider notified. If the TPN is not available for administration, the resident will be returned to the hospital. System Change: The clinical IDT will complete rounds Monday through Friday to identify any change of conditions. Element 4: How the corrective action(s) will be monitored to ensure the deficient practices will not recur, i.e., what quality assurance program, will you put in place: The DON/designee will audit 5 residents with change in condition weekly to ensure that staff met the residents' needs x's 4 weeks then monthly thereafter until substantial compliance is met and audits are discontinued by the QA committee. The audit period will be for 3 months, or until QAPI deems substantial compliance. The Administrator is responsible for ongoing compliance.