Failure to Timely Obtain and Administer TPN for Resident
Penalty
Summary
A deficiency occurred when the facility failed to timely obtain and administer Total Parenteral Nutrition (TPN) for a resident with diagnoses including perforation of intestine and peritoneal abscess. Upon admission, the resident was alert and oriented and had orders for Clinimix (a form of TPN) and Clinolipid to be administered intravenously. Despite these orders being entered on the day of admission, the TPN was not available or administered until the following day. The resident reported asking staff about her medications and experiencing pain, vomiting, and crying during this period. The resident’s family member also inquired about the missing TPN and IV antibiotics, prompting a nurse to review the medication list and obtain one antibiotic from the emergency drug kit, while the TPN was delivered via STAT order later. The delay was traced to a failure in the medication ordering process, where the TPN order was entered incorrectly and not transmitted to the pharmacy, resulting in no delivery or follow-up communication from the facility to the pharmacy. Interviews with staff and the pharmacy representative confirmed that the pharmacy did not receive the TPN order due to this error, and no notes indicated a STAT request was made on the evening of admission. The facility did not have a policy specific to TPN administration, relying instead on standard practice.