Failure to Provide Compatible TPN Equipment Resulting in Hospitalization
Penalty
Summary
The facility failed to ensure that proper pumps and intravenous tubing were provided by the pharmacy to administer Total Parenteral Nutrition (TPN) as ordered by the physician for one resident. The resident, who had a history of pancreaticobiliary cancer and recent surgery for a paraoesophageal hernia and gastric outlet obstruction, was admitted with an order for TPN. Upon admission, the TPN order was faxed to the contracted pharmacy, which confirmed receipt and stated the TPN would arrive in the overnight shipment due to the late hour. When the TPN and equipment arrived, nursing staff discovered that the tubing provided was incompatible with the pumps sent by the pharmacy. Multiple nurses, including an RN and LPNs, attempted to administer the TPN but were unable to do so because the 'blue key' on the tubing did not fit into the pump chamber. The pharmacy was contacted several times over the weekend regarding the incompatible equipment, but the issue was not resolved, and the correct equipment was not provided in a timely manner. The pharmacy indicated that their equipment department was unavailable on weekends, further delaying resolution. As a result of the failure to provide the necessary equipment for TPN administration, the resident did not receive the ordered nutrition. The resident subsequently experienced a significant drop in potassium and magnesium levels, leading to weakness, fatigue, dehydration, and ultimately required hospitalization for IV hydration and electrolyte replacement.
Plan Of Correction
F755 Pharmacy Services Severity Level D Compliance Date 04/30/2025 Element 1: What corrective action(s) will be taken Resident 502 is no longer resides in the facility. Element 2: How the facility will identify other residents having a potential to be affected by practice and what corrective action will be taken All residents with orders for TPN have a potential to be affected by the practice. Current residents residing in the facility were assessed by a licensed nurse to ensure that the current residents and all new admissions with TPN orders have pumps, tubing, and TPN solution to meet their needs on 04/17/2025. Element 3: What system or systematic changes you will make to ensure that the deficient practice does not recur The Quality Assurance committee reviewed the policy for Parenteral Nutrition and deemed it appropriate on 04/17/2025. On this date, or before their scheduled shift, we will educate Admission Directors and Nurse Managers on the Parenteral Nutrition Policy. The policy states that if a resident is admitted to the facility and is to receive TPN, the nurse is to ensure the order has been received, reviewed, and signed by the physician and faxed to the pharmacy to be received in time for the resident admission. Pharmacy will ensure needed supplies are sent with the TPN prior to resident admission. PharmScript Pharmacy is taking the TPN ordering and supply process through their QAPI and providing education to the staff to prevent future recurrence. 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 be put in place The DON/designee will audit 5 residents with TPN orders weekly to ensure proper pumps and tubing are provided by the pharmacy and TPN is available upon admission for the first 4 weeks, then monthly thereafter until substantial compliance is met and audits are discontinued by the QAPI committee. The audit period will be 3 months or until QAPI deems substantial compliance. The Administrator is responsible for ongoing compliance.