F0755

D

Failure to Label IV Medication Bag and Tubing per Policy

Fort Worth, Texas Survey Completed on 12-11-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure parenteral fluids and IV medications were administered in accordance with professional standards, physician orders, and the resident’s care plan. A male resident with septicemia, intact cognition (BIMS score of 14), and an order for daily IV Daptomycin via a PICC line had an IV medication bag in use that was not labeled with the date, time, or initials of the nurse who hung it. An additional empty IV bag in the resident’s room was also unlabeled. The resident’s care plan called for administering IV medications as ordered, monitoring the IV site for infection, flushing ports/lines as ordered, and changing dressings every seven days and as needed. The facility’s IV medication policy required recording the drug name, dose, rate, date, and time on the container label.

During observation and interviews, an LVN on duty stated she had not hung the IV bag but confirmed that IV bags and tubing were supposed to be labeled with the resident’s name, date, time, and nurse’s initials, and acknowledged that the unlabeled bag had been hung by the 2:00 PM–10:00 PM nurse. Another LVN later confirmed she was the nurse who administered the Daptomycin during that shift and admitted she knew she was required to label the IV bag and tubing but forgot to do so, despite having completed IV administration training and a skills check the previous month. Both LVNs, as well as the ADON and DON, stated that IV bags and tubing should be dated and initialed to prevent medication errors and infection, and that tubing should be changed every 24 hours. The facility’s failure to ensure labeling of the IV bag and tubing for this resident constituted the cited deficiency in pharmaceutical services and IV administration practices.