Failure to Provide Qualified Staff for IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure that qualified staff were available to administer intravenous (IV) medication through a Peripherally Inserted Central Catheter (PICC) line for a resident who required this level of care. The resident, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and Crohn's disease, was admitted and later readmitted to the facility. Following a hospital visit for a urinary tract infection, the resident was discharged with a new order for vancomycin IV to be administered every twelve hours via a PICC line. The medication was delivered to the facility, but was not administered as ordered. Documentation and staff interviews revealed that the doses of vancomycin scheduled for administration were missed because there was no Registered Nurse (RN) available to initiate the medication through the PICC line. The Director of Nursing (DON) confirmed that she was the only RN on staff and was not present to administer the medication, and the Assistant Director of Nursing (ADON) was no longer employed at the facility. Facility policy required that medication be administered without unnecessary interruptions and in accordance with prescriber orders, but this was not followed due to the lack of qualified staff.