Failure to Label TPN Bag and Tubing per Protocol
Penalty
Summary
Facility staff failed to administer total parenteral nutrition (TPN) in accordance with professional standards of practice for one resident. Specifically, the TPN bag and the peripherally inserted central catheter (PICC) line tubing were not labeled with the date and time they were started. This was observed during a random screening, and the omission was confirmed by a registered nurse, who acknowledged that facility policy requires all TPN bags, medications, and tubing to be labeled with the date and time to ensure proper tracking and reduce confusion among nursing staff. The resident involved had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder. The resident was dependent on staff for all activities of daily living and was rarely or never able to communicate or make decisions. The care plan for this resident included an intervention to change tubing according to protocol, but this protocol was not followed as evidenced by the lack of labeling on the TPN bag and tubing.