Unqualified Staff Attempted IV Insertion
Penalty
Summary
A deficiency occurred when a medication aide, who was not licensed or qualified to perform intravenous (IV) catheter insertions, attempted to insert a peripheral IV catheter into a resident's arm. The resident involved had significant medical conditions, including arthritis, dementia, Alzheimer's disease, and diabetes mellitus, and was severely cognitively impaired and dependent on assistance for daily living activities. The resident had a physician's order for IV fluids, and the assigned nurse was unable to establish IV access after an attempt. After the nurse left the room, the medication aide, who was present to assist and calm the resident, asked the resident for permission to attempt the IV insertion. The aide proceeded to use the needle from an IV catheter kit and made one attempt to insert the catheter, achieving blood return but failing to maintain IV access due to vein collapse. This action was witnessed by another medication aide, who assisted in covering the site and later reported the incident to nursing leadership. The medication aide who attempted the procedure was attending nursing school and had practiced IV insertions but was not authorized or competent to perform this task in the facility. Multiple staff interviews and written statements confirmed that the medication aide acted outside her scope of practice by attempting the IV insertion. The incident was not immediately reported to the nurse who had left the room, and the nurse only became aware of the event the following day. The facility's staff, including medication aides and nurse aides, were not licensed or trained to perform IV insertions, and this incident represented a failure to ensure that only qualified personnel provided care according to each resident's written plan of care.