Failure to Properly Label and Document IV Site for a Resident
Penalty
Summary
A deficiency was identified when a resident receiving intravenous (IV) antibiotic therapy for a left lower leg venous ulcer/cellulitis did not have their peripheral IV (PIV) site properly labeled according to facility policy. During an observation, the PIV label was found to be missing the time of insertion, the initials of the staff member, and the length and gauge of the catheter. The registered nurse present confirmed these omissions. The facility's policy required that the label include the date and time of insertion, initials, and catheter details, but these were not present on the observed label. Further review of the resident's medical record and IV administration record revealed inconsistencies regarding documentation of the IV site change. Although the label on the IV site indicated a change on a specific date, there was no corresponding documentation in the nurse's notes or IV administration record to confirm that the site was changed as required. The Director of Nursing verified the absence of this documentation during a review.