F0694

D

Unsafe TPN Administration via Gravity Drip and Order Discrepancies

Salt Lake City, Utah Survey Completed on 01-21-2026

Penalty

No penalty information released

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.