F0694

D

Unlabeled IV Vancomycin Bag Hung for a Resident Receiving PICC Infusion

Harlingen, Texas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the administration of IV medications when a resident receiving IV vancomycin via a PICC line had an unlabeled IV medication bag in use. The resident was an adult with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, cellulitis of the lower limb, a stage 4 sacral pressure ulcer, muscle weakness, paraplegia, and a need for assistance with personal care. The care plan included administration of antibiotics per physician orders, and the physician had ordered vancomycin 1 gram IV every 8 hours for sacral wound infection, sacrococcygeal osteomyelitis, and cellulitis. During observation, the IV bag actively infusing into the resident’s PICC line was found to have only a date and nurse’s initials written in black marker, with no resident name, medication dose, frequency, or route indicated.

In an interview, the RN who hung the IV bag acknowledged that he had just hung the bag, had thrown away the original label, and was aware that the bag was missing the required medication label information. He stated he knew the bag was supposed to include the resident’s name, dosage, frequency, and route, and acknowledged that failure to label the medication properly could lead to administering the wrong medication to the wrong resident or cause an infection. The DON confirmed that the RN knew he was required to label the IV medication bag and stated that she expected all nurses to label medications appropriately prior to administration, and that it was the administering nurse’s responsibility to verify that everything was labeled correctly. The facility’s policy on administration of IV medications and fluids required verification that the container’s label coincides with the prescriber’s order, including content, dose, prescribed rate, and expiration date of the solution.