Failure to Clean IV Medication Port Prior to Mixing Antibiotic
Penalty
Summary
Nurse #1 was observed preparing an intravenous antibiotic medication for a resident by gathering a normal saline bag and a vial of Cefepime powder. After performing hand hygiene and donning gloves, Nurse #1 connected the antibiotic vial to the normal saline bag without cleaning the medication port of the saline bag with an alcohol swab. The nurse then mixed the antibiotic with the saline for administration. During an interview, Nurse #1 stated that she believed the medication port did not require cleaning with alcohol prior to mixing, despite the normal saline bag not being in a sterile package. The Director of Nursing (DON), who also serves as the Infection Preventionist, confirmed that facility procedure requires cleaning medication ports with an alcohol pad before connecting and mixing medications, a process intended to prevent bacterial contamination. The Administrator also confirmed that the expectation is for medication ports to be cleaned prior to mixing medications, in accordance with facility procedures.