Improper Administration of IV Flushes Following Antibiotic Therapy
Penalty
Summary
Licensed staff failed to administer saline and heparin intravenous flushes according to facility policy and standard of care for a resident with a central line receiving antibiotic therapy. The resident, who was cognitively intact and had an artificial hip joint infection with an open hip wound, had physician orders specifying the use of a central line for intermittent infusions. The orders directed that the central line be flushed with 10 mL of saline before medication administration, and after medication administration, flushed with 10 mL of saline followed by 5 mL of heparin. However, observation revealed that an LPN flushed the central line first with 5 mL of heparin and then with 10 mL of saline, contrary to the prescribed order and facility protocol. Interviews with the LPN and the Director of Nursing Services (DNS) confirmed that the facility uses the SASH protocol (Saline, Antibiotic, Saline, Heparin) for central line maintenance, which was also reflected in the facility's IV management policy. The LPN admitted to possibly misreading the order and was unsure why the sequence was reversed. The DNS was also unable to explain the deviation from protocol. The deficiency was identified through observations, staff interviews, and review of facility policy and resident records.