Failure to Label IV Tubing for Resident Receiving Parenteral Fluids
Penalty
Summary
A deficiency was identified when a resident receiving intravenous (IV) fluids did not have their IV tubing labeled with the date, time, and nurse's initials, as required by facility policy and professional standards. The resident, a female recently admitted with a history of cerebral infarction and gastrostomy status, was observed with a PICC line and IV fluids in place. During multiple observations, surveyors noted that the IV tubing lacked proper labeling, and this was confirmed by interviews with nursing staff and facility leadership. The nurses involved acknowledged awareness of the requirement to label IV tubing and admitted to missing this step, with one nurse stating she forgot and another stating she failed to check the tubing when taking over the shift. Facility policy required IV bags and tubing to be labeled with the date and nurse's initials when placed into use. Both the ADON and Interim DON confirmed their expectation that staff follow this policy and check equipment status at shift change. The failure to label the IV tubing was observed by both nursing staff and facility administration, and it was acknowledged that this omission could lead to infection. Training records indicated that the involved nurses were IV certified, and the facility's policy on intravenous fluid management was reviewed, which reiterated the labeling requirement.