Failure to Label IV and TPN Sites and Tubing per Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice for infusion therapy in the care of two residents. For one resident with a history of gangrene and peripheral vascular disease, the peripheral intravenous (IV) site was not labeled with the date and initials upon insertion or dressing change, as required by facility policy. This omission was confirmed during observation and interview with nursing staff, who acknowledged that the labeling was necessary for infection control and to track when the dressing was last changed. The resident's care plan and facility policy both specified the need for dating and initialing the IV site dressing. For another resident receiving total parenteral nutrition (TPN) through a central venous catheter due to diagnoses including bladder cancer and anemia, the TPN administration set was not labeled with the date and time when it was hung. Observation and interviews with nursing staff and the DON confirmed that the tubing was unlabeled, contrary to facility policy, which required labeling to ensure proper infection control and to document when the tubing was last changed. Both deficiencies were identified through direct observation, record review, and staff interviews.