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:
A resident with osteomyelitis and a PICC line had physician orders for IV Vancomycin twice daily and IV Cefazolin every 8 hours, but the MAR lacked documentation for several scheduled doses. Specifically, morning Vancomycin doses and an afternoon Cefazolin dose were not recorded, despite facility guidelines requiring nurses to sign the MAR immediately after medication administration.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A resident admitted with wound infection and bacteremia received IV vancomycin via a midline catheter, but staff failed to follow facility policy and physician orders requiring measurement and documentation of the external catheter length. The care plan identified risk for complications related to the midline and called for measuring and documenting the external catheter length during dressing changes, yet the admission external length was left blank and no subsequent measurements were recorded. Observation confirmed the resident had IV access for antibiotic administration, and the DON acknowledged that the external catheter length was never documented and no insertion-length information was obtained from the hospital.
PICC line care was not consistently completed or documented for two residents with PICC lines for IV antibiotics. One resident with COPD and another resident with chronic osteomyelitis had orders for daily external PICC length measurements, but records showed missed documentation on multiple days. For one resident, ordered PICC dressing and cap changes every 7 days were also not documented. The Regional Administrator of Clinical Operations stated the facility did not consistently monitor and maintain the PICC lines in accordance with physician orders, facility policy, and professional standards of practice.
A resident with multiple sclerosis, respiratory failure, sepsis, and severely impaired cognition received IV Vancomycin for pneumonia, but the IV dressing was not labeled with the insertion date, time, or staff initials. During the infusion, the RN supervisor later found the IV had infiltrated with redness and swelling. Facility policy required IV site labeling and ongoing assessment for infiltration, phlebitis, and infection.
A resident with cancer, malnutrition, and recent hypotension had a physician’s order for peripheral IV NS hydration over four hours on three consecutive days. The IV hydration ordered for the first day was not administered as scheduled and was instead initiated late the following day by an RN, who reported that the prior shift had not carried out the order and that no IV line was in place at the start of her shift. The DON later stated she was unaware of the missed dose and acknowledged the importance of the hydration given the resident’s hypotension. Facility IV P&P required timely initiation of infusion therapy when ordered and available from the e-kit, but this was not followed.
Failure to Document Ordered IV Antibiotic Administration on MAR
Penalty
Summary
The facility failed to ensure that a resident’s IV antibiotic therapy was accurately documented on the medication administration record (MAR) as ordered by the physician. The resident, who had osteomyelitis and a PICC line in the right upper extremity, had a physician’s order dated 4/8/26 for Vancomycin HCl 1.25 grams IV twice daily at 8:00 a.m. and 8:00 p.m. The April 2026 MAR lacked documentation of the 8:00 a.m. Vancomycin doses on 4/23/26 and 4/27/26. A subsequent physician’s order dated 4/20/26 directed Cefazolin Sodium 2 grams IV every 8 hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. for the same diagnosis, and the April 2026 MAR lacked documentation of the 2:00 p.m. Cefazolin dose on 4/23/26. During the survey, the resident was observed with an active PICC line, and staff confirmed that the MAR should be signed by the nurse administering the medication. The Regional Director of Operations provided the facility’s Medication Administration Guidelines, which state that the MAR is to be signed immediately after administering medications, under “The Right Documentation.” Despite this policy, the MAR entries for the specified IV antibiotic doses were not completed, resulting in missing documentation for multiple ordered IV antibiotic administrations.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Failure to Measure and Document External Midline Catheter Length for IV Therapy
Penalty
Summary
The facility failed to administer IV therapy in accordance with professional standards of practice and physician orders for one resident with a midline catheter. Facility policy for central venous catheter dressing changes, dated May 2011, required an RN to measure the external portion of the catheter, document this measurement in the electronic medical record, ensure it matched the IV insertion records, and notify the physician of any discrepancies. The resident’s comprehensive care plan, initiated shortly after admission, identified risk for complications related to the midline and included an intervention to measure and document the length of the external catheter during dressing changes; however, the external length on admission was left blank in the care plan. The resident was admitted with diagnoses of wound infection and bacteremia and had a physician order for IV vancomycin every 12 hours for 21 days, as well as a subsequent order to measure the external catheter length with each weekly dressing change. The MDS indicated the resident received IV therapy for antibiotic medications while in the facility. Observation confirmed the resident had IV access for antibiotic administration. Review of the clinical record revealed no documented evidence that the external catheter length was measured and documented on admission or with any dressing changes thereafter. The DON confirmed that the facility did not document the resident’s external catheter length and did not have documentation from the hospital regarding the external catheter length at the time of insertion.
Plan Of Correction
1. All PICC lines will be measured in accordance with facility policy 2. The policy on Central Venous Catheter Dressing Change (PICC Line) will be updated as needed. 3. The licensed nursing staff will be in-serviced by the ADON or designee on policy changes. 4. As part of routine clinical review meeting, the ADON will verify PICC line measurements are being completed according to policy 5. For the next 60 days, the ADON or designee will complete an audit to verify compliance. 6. Results of the audit will be reported to facility QA team.
PICC Line Monitoring and Dressing Care Not Completed as Ordered
Penalty
Summary
The facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for two residents with PICC lines. Facility policy for central venous catheter care stated that IV site care and dressing changes were required at established intervals or immediately if the dressing was damp, loosened, or visibly soiled, and that the external length of the catheter should be measured with each dressing change or if dislodgement was suspected. The policy also directed staff to check the State Nurse Practice Act regarding LPN scope of practice for central venous catheter dressing care. Resident 1, who was cognitively intact and had a PICC line for antibiotic administration, had a physician order requiring daily measurement of the external PICC length, but the eMAR showed no documentation of measurements on February 5, 11, 24, 25, and 26, 2026. Resident 30, who was cognitively intact and had a PICC line for antibiotic administration related to chronic multifocal osteomyelitis of the left ankle and foot, also had an order for daily external PICC length measurement, but the treatment record showed no documentation on March 14, 15, and 21, 2026. In addition, physician orders required PICC dressing and cap changes every seven days for Resident 30, and the treatment administration record showed no documentation that those changes were completed at the required intervals. The Regional Administrator of Clinical Operations stated the facility did not consistently monitor and maintain PICC lines in accordance with physician orders, facility policy, and professional standards of practice for Residents 1 and 30.
IV Site Not Properly Labeled or Monitored During Vancomycin Infusion
Penalty
Summary
The facility failed to ensure safe, appropriate administration and monitoring of IV fluids for one sampled resident who was receiving IV Vancomycin for ventilator-associated pneumonia. The resident had multiple sclerosis, respiratory failure, sepsis, and severely impaired cognition, and was dependent on staff for personal care. The order required Vancomycin 1 gram IV every 12 hours and daily and nightly monitoring of the peripheral IV site for signs of infection or infiltration. On observation, the resident was receiving Vancomycin through a left hand IV access, and the IV site dressing did not have the insertion date, time, or staff initials. The RN supervisor stated she had started the infusion about one hour earlier and, on reassessment, found the IV had infiltrated with redness and swelling. The DON stated staff must label the IV dressing with the insertion date, time, and initials, and that the IV site should be reassessed after initiation of IV medication. Facility policies also required labeling of the IV dressing and ongoing assessment for infiltration, phlebitis, infection, redness, swelling, pain, warmth, leakage, and other signs of IV complications.
Failure to Timely Administer Ordered IV Hydration
Penalty
Summary
The facility failed to administer ordered IV hydration as prescribed for one resident. The resident had diagnoses including malignant neoplasm of the lungs and bones, neoplasm-related pain, and malnutrition, and required varying levels of assistance with activities of daily living, including partial/moderate assistance with eating and oral hygiene and dependence for toileting, showering, lower body dressing, and footwear. A physician’s order dated 4/10/2026 directed that the resident receive peripheral IV hydration with normal saline over four hours on 4/10/2026, 4/11/2026, and 4/12/2026. However, the IV hydration ordered for 4/10/2026 was not administered on that date. During record review and interview on 4/23/2026, an RN reported that when she began her 7 AM–3 PM shift on 4/11/2026, it had been endorsed to her that the IV hydration order from the previous night had not been carried out, and the resident did not have an IV line in place at the start of her shift. The RN initiated the peripheral IV line and IV hydration on 4/11/2026 at around 11 AM. The DON stated she was not aware that the IV hydration ordered for 4/10/2026 had not been administered until 4/11/2026 and noted that the IV hydration order was important because the resident had experienced hypotension on 4/9/2026. The facility’s IV policy indicated that when an IV order is received, pharmacy should be called or faxed with IV orders, and if fluids and medications are available from the emergency kit supply, infusion therapy should be initiated as ordered in a timely manner. This policy was not followed for the IV hydration ordered on 4/10/2026.
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