Failure to Follow IV Therapy Protocols and Documentation Requirements
Penalty
Summary
The facility failed to follow its own policies and procedures regarding intravenous (IV) therapy for two residents. For one resident with diagnoses including type 2 diabetes and osteomyelitis, the IV tubing used to administer Ceftriaxone was observed to be unlabeled during a room visit. The licensed vocational nurse confirmed the tubing was not labeled and acknowledged that labeling is required to track the age of the tubing and prevent bacterial contamination. The Director of Nursing also verified that the facility's policies require IV tubing to be labeled with the date and time for infection control purposes, and that failure to do so violates both the infection prevention and administration set/tubing change policies. For another resident with a history of ESBL-resistant Klebsiella infection and Alzheimer's disease, the care plan required IV site monitoring every shift while receiving Ertapenem. Review of the IV therapy medication record revealed that there were no registered nurse initials indicating that the IV site was checked during multiple night shifts. Interviews with nursing staff confirmed that the IV site was not checked or flushed as required, and the MDS nurse verified that documentation was incomplete, stating that if it was not documented, it was not done. The facility's policy specifies that the venous access site must be monitored and documented at least every shift. These deficiencies were identified through observation, interviews with staff, and review of medical records and facility policies. The failures included not labeling IV tubing and not consistently monitoring and documenting IV site assessments as required by the facility's infection control and IV therapy protocols.