Failure to Follow Infection Control Protocols During IV Therapy
Penalty
Summary
The facility failed to properly handle intravenous (IV) tubing and follow evidence-based protocols during IV medication administration for a resident with a peripherally inserted central catheter (PICC) line. Observations revealed that the IV tubing was left without an end cap and was hanging 2 to 3 inches above the floor, connected to a new bag of meropenem, with no date labeled on the tubing. Two empty medication bags and a syringe cap were found in the trash, and the tubing was not dated as required by facility policy. During the administration of the IV medication, the LPN did not wear a gown as required under Enhanced Barrier Precautions (EBP) and was unsure about the frequency of IV tubing changes or the meaning of EBP. The LPN also admitted to discarding the original end cap and not replacing it, leaving the tubing uncapped. The resident involved had a diagnosis of major orthopedic surgery and a physician's order for meropenem IV infusions related to atherosclerosis with ulceration. The facility's policies required that intermittent administration sets used more than once in 24 hours be capped with a sterile end cap, labeled with date and time, and changed every 24 hours. The Director of Nursing confirmed that the observed practices did not align with facility policy, as the tubing should have been capped, dated, and the staff should have worn both gown and gloves for EBP. The LPN's lack of knowledge regarding EBP and proper IV tubing handling contributed to the deficiency.