Failure to Ensure Complete IV Antibiotic Administration and Secure IV Site
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus did not receive intravenous (IV) antibiotic medication as ordered. The physician's order and care plan required the administration of Ertapenem Sodium 1 gram IV every 24 hours for a UTI, with the expectation that the IV site would be maintained and free of complications. However, during observation, it was found that the IV antibiotic bag, which should have been completely infused by 6:30 a.m., still had 40 cc remaining at 11:15 a.m., indicating the medication was not fully administered. The Assistant Director of Nursing confirmed that the medication should have been completely infused and that failure to do so would not treat the infection. Further observation revealed that the resident's saline lock needle tip was dislodged and lying on the skin, rather than being properly inserted into the vein. The registered nurse acknowledged that a patent saline lock should be in the vein to administer IV medications. Review of facility policy confirmed that nurses are required to monitor the IV site frequently for complications and ensure proper administration. These failures resulted in the resident not receiving the complete dose of antibiotic medication and the IV site not being securely maintained.