Unsafe TPN Administration via Gravity Drip and Order Discrepancies
Summary
The deficiency involves the unsafe and inappropriate administration of TPN/IV fluids to a cognitively intact resident with multiple complex medical conditions, including CHF, chronic pulmonary edema, chronic kidney disease, kidney transplant status, malnutrition, intestinal fistula, and electrolyte disorders. The resident had an order for evening TPN with pharmacy instructions specifying a compounded volume of 1800 ml, including start and end taper periods, and a total run period of 16 hours. However, the pharmacy label on the TPN bag directed infusion of 1800 ml at 125 ml/hr over 12 hours, and there were discrepancies between the pharmacy order summary (with tapering start and end rates and volumes) and the label directions. The DON later acknowledged that the label directions did not match the calculated infusion time for the stated volume and rate and that there was confusion in how the order was written. On the evening of the incident, an agency RN initiated the resident’s ordered TPN infusion between approximately 7:30 PM and 8:00 PM. The agency RN reported that an IV pump was not present in the room and manually calculated the drip rate, regulating the infusion via the roller clamp and counting drips per minute, rather than using an IV pump. It was later confirmed that an IV pump was in fact present in the room. The agency RN did not document or report the duration of infusion used to calculate the drip rate. Between 10:00 PM and 10:30 PM, the agency RN reported that the TPN bag was about half full before leaving the shift. At around 10:00 PM, the oncoming facility RN assumed care of the hallway and later, at approximately 11:01 PM, entered the resident’s room and found the TPN bag empty, connected directly to the PICC line and not routed through the IV pump. The progress note documented that the resident had already received the full TPN volume even though it was scheduled to run over 12 hours, and the facility’s abuse investigation determined that the TPN had infused over about 3 hours and 15 minutes instead of the ordered 12 hours. Following the rapid infusion, the resident’s condition changed. At about 11:01 PM, the resident’s blood sugar was documented as 450, and vital signs and neuro checks were performed, with subsequent neurological assessments showing elevated HR, elevated BP, increased RR, and progressive changes in level of consciousness and motor response from baseline over the night and into the morning. The resident became lethargic with altered mental status, was more difficult to arouse, and later complained of chest pain, headache, nausea, and confusion. A physiatry follow-up note described the resident as lethargic, arousable only to loud voice and tactile stimulation, and reporting constant sharp chest pain. EMS was called later that morning due to chest pain, low BP, fever, and high HR, and the resident was transferred to the hospital, where she was noted to be febrile, tachycardic, initially hypotensive, and confused, with differential diagnoses including sepsis and line sepsis. The facility’s emergency transfer form did not document that the resident had received a TPN bolus the prior night, and the hospital documentation did not reflect that the TPN bolus and associated change in condition had been communicated. The facility’s own investigation substantiated that the resident received TPN incorrectly as a bolus over a short period rather than as ordered. The facility’s PN policy required that PN be tapered up over 1–2 hours, run at a set rate for a determined time, and then tapered down over 1–2 hours, and specifically stated that PN should never be stopped suddenly and that tapering is needed to prevent hypoglycemia. The pharmacy order summary for this resident’s TPN included start and end taper periods and a total run period of 16 hours, but the pharmacy label and the way the order was presented created inconsistencies in the documented volume, rate, and duration. The DON acknowledged that the nurse should have clarified the discrepancies with the pharmacy and followed up with the physician. The DON also confirmed that the TPN label indicated infusion at 125 ml/hr with a total volume and duration that did not mathematically align, and that there was confusion with the order as written. Despite these documented inconsistencies and the presence of an IV pump in the room, the TPN was administered via gravity drip and infused in a fraction of the intended time, leading to a substantiated medication administration error and associated change in the resident’s condition.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
IV access and medication labeling deficiencies: A resident with a PICC line had no documented admission measurement of external catheter length or arm circumference, another resident’s IV tubing was observed without the required date, time, and RN initials, and a third resident’s meropenem IV bag was not labeled with the date, time, and initials. Facility policy required labeling of IV solutions and documentation of PICC measurements.
Failure to Document Baseline Midline IV Measurements: A resident receiving IV antibiotics via a midline IV had no documented baseline external catheter length or arm circumference measurements when admitted from the acute hospital. The resident’s care plan did not address the midline IV, and the IV MAR lacked baseline documentation. RN confirmed staff performed dressing changes and measurements, but could not verify any baseline values from the acute care hospital; the DON verified the findings.
A resident with a PICC line, diabetes, obesity, atrial fibrillation, and CHF had no documented PICC-related care plan interventions, and the PICC dressing was found stained, loosening, and dated well beyond the weekly change schedule. Although the MAR showed the dressing change as completed, staff interviews confirmed it was overdue and should have been changed sooner, with the DON acknowledging it was late and that loose or soiled dressings require more frequent attention.
A resident received IV Cefepime multiple times through a long-term IV catheter, but the MAR lacked documentation that the catheter was flushed before and after administration as required by facility policy. The DON confirmed the nurse should have flushed the IV catheter pre- and post-medication administration.
A resident receiving IV antibiotics through a PICC had no documented baseline or weekly catheter length and arm circumference measurements, despite an order for the RN to record them after each Sunday dressing change. RNs stated the measurements were needed to confirm the catheter remained in position, but the IV MAR showed only dressing changes and no measurements. The DON confirmed the record lacked both admission and weekly measurements, and the complaint noted the catheter had moved, leading to a hospital return, PICC removal, and replacement catheter placement.
PICC Line Removal Not Timely or Fully Documented: A resident with severe cognitive impairment, dependence for all ADLs, and IV antibiotic therapy had a PICC line that was not removed when the antibiotic ended, and nursing documentation showed conflicting removal entries. The chart lacked a physician order for removal, lacked confirmation that the full line including the tip was removed, and lacked documentation of post-removal site inspection or monitoring for complications.
IV access and medication labeling deficiencies
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for Resident 23, who had a right upper arm single lumen PICC line and a BIMS score of 12 on admission. The resident’s medical record showed a physician’s order to measure the external catheter length of the PICC and midlines upon admission and with each dressing change, and to include arm circumference for the midline device every seven days and as needed. However, the Nursing Admission/readmission Evaluation/assessment did not document the measurement and assessment of the PICC line, and the record did not show evidence that the length of the catheter above the insertion site or arm circumference were obtained upon admission. The facility also failed to ensure Resident 123’s IV tubing was labeled. During an initial tour, Resident 123 was observed with a peripheral IV in the left hand and a one-liter bag of 0.9% Sodium Chloride infusing at 75 mL per hour. The IV tubing was not labeled with the date, time, and nurse’s initials. The resident’s order summary showed an order to change IV tubing every 24 hours for intermittent IV infusion and TPN and every 72 hours for continuous IV infusion. In addition, the facility failed to ensure Resident 9’s IV medication was correctly labeled. During medication administration observation, Resident 9 was observed with a right upper arm three lumen PICC line and meropenem 1 gram was prepared and administered through the PICC line. The IV tubing was labeled by the RN, but the meropenem medication bag was not labeled with the date, time, and initials of the RN who administered the medication. Facility policy stated that the nurse hanging IV solutions will label the bag with the date, time, and initials.
Failure to Document Baseline Midline IV Measurements
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the intravenous access for Resident 68, who had a midline IV in the left upper arm with two lumens and a transparent dressing. The resident had physician orders for antimicrobial disc use, routine flushing of the midline lumen, monitoring for inflammation or infiltration every shift, measuring arm circumference 5 cm above the insertion site during dressing changes, changing the midline dressing and Stat-lock weekly, and measuring the external catheter length during dressing changes with notification to the MD if the length increased by 2 cm or more. Medical record review showed no baseline documentation of the external catheter length or arm circumference above the insertion site when the resident arrived from the acute hospital where the midline was inserted. The resident’s care plan did not address the midline IV, and the IV Administration Record for April and May 2026 did not show baseline arm circumference or catheter length measurements documented on admission. During interview and record review, RN 1 confirmed the resident was receiving IV antibiotics through the midline and stated nursing staff were responsible for dressing changes and measurements, but could not verify any baseline measurements from the acute care hospital. The DON later reviewed and verified these findings.
PICC Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure parenteral fluids and central venous catheter care were provided in accordance with professional standards of practice and physician orders for one resident with a PICC line. The resident was admitted with diagnoses including cellulitis of the left lower limb, type 2 diabetes mellitus, morbid obesity, unspecified atrial fibrillation, and acute-on-chronic systolic heart failure, and had a BIMS score of 15 indicating intact cognition. The baseline care plan contained no documented interventions, monitoring, or care planning related to the PICC line or IV antibiotic therapy. The order summary included an order to monitor the PICC site every shift for signs and symptoms of infection and an order to change the PICC dressing weekly and every Monday. Although the MAR documented the PICC dressing change as completed on 05/18/26, an observation and interview on 05/19/26 found the PICC dressing visibly stained, loosening around the edges, and dated 05/08/26. The resident stated the dressing had not been changed since admission. Staff interviews confirmed the dressing should have been changed the prior day, that a loose or rough dressing could be changed more frequently under PRN orders, and that the RN charge nurse was going to change it that day. The DON stated PICC lines are to be changed every 7 days and acknowledged the dressing should have been changed the day before.
Failure to Flush IV Catheter During Antibiotic Administration
Penalty
Summary
Professional standards of practice were not followed for the care of a resident's long-term IV catheter. Resident 8 had physician orders for IV Cefepime HCl, including 2 grams every 12 hours for seven days and a one-time 2 gram dose, and the facility's IV catheter policy required flushing the catheter with 5 ml of normal saline before and after infusion. Review of the MARs for April and May 2026 showed that staff administered IV Cefepime 14 times, but there was no documented evidence that the IV catheter was flushed before or after medication administration. The DON confirmed in interview that the nurse should have flushed the IV catheter pre- and post-medication administration.
PICC Line Measurements Not Documented
Penalty
Summary
The facility failed to ensure a PICC line was measured weekly for a resident receiving IV antibiotics for a bone infection. Resident 1 was admitted with diagnoses including an infection in the bone and had a physician order for the RN to change the PICC dressing and securement device every Sunday and to measure the catheter length and arm circumference in centimeters after each dressing change. RN interviews stated that the measurements were important to confirm the catheter remained in the correct position and to monitor for infection, and that the Sunday dressing change process included use of a measuring tape. Record review of the IV MAR for April and May 2026 showed dressing changes were documented on 4/19/26, 4/26/26, and 5/3/26, but no catheter length or arm circumference measurements were recorded. The DON stated the admission measurements should have been obtained from the hospital or measured on arrival to establish a baseline, and that the absence of both admission and weekly measurements meant the facility could not compare values to confirm the catheter remained in place. The complaint also stated the catheter had moved out of its original position, and Resident 1 returned to the hospital with chest pain, had the PICC removed, and received another catheter to complete medication administration.
PICC Line Removal Not Timely or Fully Documented
Penalty
Summary
The facility failed to provide services consistent with the standards of care related to Resident 4’s PICC line when the physician’s order for in-facility removal after completion of IV antibiotic therapy was not followed for three days. Resident 4 had diagnoses including anxiety, diabetes mellitus, aphasia following cerebral infarction, and pressure ulcers to both heels, and the MDS documented severely impaired cognition with a BIMS score of zero, dependence on staff for all ADLs, impairment of both upper and lower extremities, and receipt of IV medications during the observation period. The care plan did not address the PICC line or associated care. The record showed orders for PICC dressing changes, cap changes, and daily saline flushes, and documentation stated to continue Daptomycin/Cerftiax through 05/08/26 and then remove the PICC line. Nursing notes documented the PICC line was removed on 05/12/26 and again on 05/13/26, but the chart lacked a physician order to remove the line and lacked documentation confirming the full removal of the line, including the tip. The record also lacked documentation of inspection of the PICC line after removal to ensure it was fully removed without complications. Administrative nurses stated the order had been sent to department heads, nursing had not done anything with it, and the facility should document the removal and any monitoring or complications.
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