MONTEZUMA, GA- MONTEZUMA HEALTH CARE CENTER

Based on observation, staff interview, record review, and a review of the facility’s policy titled, Intravenous Antibiotic, the facility failed to ensure all nursing staff had the competencies and skill set necessary to provide care for residents receiving intravenous therapy through an Intravenous Infusion Pump for one of two residents (R) (#4) reviewed for intravenous therapy. This failure had the potential for residents to have a decline in health status.

Findings include:

Review of the undated policy titled, Intravenous Antibiotic, intravenous antibiotics may be administered via a variety of modes, such as: small volume minibags administered intermittently, programmable infusion pumps allowing intermittently intervals, and a keep-vein-open rate between intervals and prefilled disposable
antibiotic infusion device.

A review of the facility provided Facility Assessment reviewed date 05/22/2023 revealed the facility accepts residents with special treatments – intravenous (IV) medications: Number/Average or Range of Residents – 2.

A review of the facility’s Skill Checklist – Core Competency form revealed that initials will indicate that the following skills have been successfully demonstrated during peer orientation. These skills represent core nursing competencies and should not be performed until demonstrated to an appropriately trained person.

These skills represent those needed for the annual review as well. Intravenous is included on the checklist.

A review of the facility’s job description for LPN Charge Nurse for Impatient Services revised 3/2022 revealed: Essential Duties and Responsibilities – IV implementation and administration.

A review of the facility’s job description for RN Nurse Supervisor for Inpatient Services revised 3/2022 revealed: Summary – Responsible for directing nursing care of the patients. Essential Duties and Responsibilities – Monitors the work of other nursing staff care to the unit for thoroughness, makes rounds to provide care to and cleanliness of patients, and implements the educational program.

Record review in the Electronic Medical Record (EMR) of the Admission Record for R#4 revealed multiple diagnoses to include infection and inflammatory reaction due to internal right knee prosthesis and Methicillin-resistant Staphylococcus aureus (MRSA) to the right knee.

Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating she was cognitively intact, and she had IV medications administered while a resident with a diagnosis as infection and inflammatory reaction due to internal right knee prosthesis.

Record review of the care plan in the EMR for R#4 revealed the resident has an infection, new or recently diagnosed administer medications and/or treatment as ordered. Diagnostics as ordered, monitor vital signs, and notify MD.

Record review of the Physician’s Orders for R#4 revealed an order for R#4 to receive vancomycin 1 gram (gm)/200 milliliters (mL) in dextrose 5 % intravenous piggyback (vancomycin in 5 % dextrose in water) 100 ml intravenously every 24 hours on at 6 a.m. for 37 days. Please allow for the trough to be collected prior to administering medication if the trough is scheduled. Please check the trough schedule prior to administering. Order start date 6/15/2023.

A review of the educational in-services provided revealed that the licensed staff did not receive formal training related to the operation/use of intravenous infusion pumps.

A review of the Electronic Medication Administration Record (EMAR) revealed that vancomycin 1gm was documented as administered on 7/01/2023 at 6 a.m.

Observation and interview on 7/1/2023 at 8:13 a.m. revealed R#4 lying in bed. There was an undated full IV bag of vancomycin 1gm observed hanging on the IV pole. Further observation revealed that the infusion pump was off, and the IV tubing was connected to the resident’s Peripherally Inserted Central Catheter (PICC) on the left arm. R#4 stated that the nurse came in and informed her she was starting her IV antibiotic and hung the medicine before the day shift this morning. R#4 further stated that she had surgery on her right knee and now had an infection in the knee, as the reason for the IV medicine she is currently receiving.

Interview and observation on 7/1/2023 at 8:30 a.m. with Licensed Practical Nurse (LPN) CC observed LPN CC enter R#4’s room, assess her pain level, administer pain medication by mouth, and exit the room. LPN CC returned to R#4’s room at 8:41 a.m. and began to disconnect the IV Vancomycin from the PICC line. LPN CC verified that the dose had not been infused, the pump was off, and the IV bag was not dated or timed prior to being hung for administration. LPN CC revealed that the medication was scheduled to be administered at 6 a.m., and she had no idea as to the reason the medication was not infused. LPN CC stated she relieved the night nurse (agency nurse) at 7:15 a.m., but the nurse did not inform her that the medicine was not infused as ordered. LPN CC continues to state she entered R#4’s room at approximately 7:45 a.m. but did not notice the antibiotic was not infused and connected to the resident. LPN CC stated that she had received orders on 6/30/2023 from the pharmacy to resume the vancomycin 1gm on 7/1/2023.

Interview and observation on 7/1/2023 at 8:44 a.m. with Assistant Director of Nursing (ADON) verified that the vancomycin 1gm still hanging and had not been infused. The ADON reviewed the EMAR and stated that the 6 a.m. dose of vancomycin for 7/1/2023 was documented as administered. The ADON also stated that there was not a progress note to reflect that the medication was not administered and/or that the medical provider was not notified according to the documentation. The ADON revealed that the medication was scheduled to be administered at 6 a.m., and the nurse had one hour before and one hour after the time to administer the dose. The ADON further revealed that the agency night nurse did report to her prior to leaving that she was unable to get the infusion pump to work to administer the dose of IV medication. The ADON
stated she was supposed to have checked off on the pump, but she had not done so. ADON stated that she was not sure if the agency nurse knew how to operate the IV pump or had any training in the operation of the infusion pump. In addition, ADON stated that she had worked at the facility since January 2023 and did not have formal training on the use of the IV infusion pump.

Interview on 7/1/2023 at 8:54 a.m. with Registered Nurse (RN) EE revealed that she is new to the facility and is shadowing another nurse today. She further stated that she had completed the classroom portion of orientation but had not received any training related to the IV infusion pump at the time of this interview. RN EE stated that she had been a nurse for a long time and was sure she would be able to figure out the operation of the pump.

Interview and observation on 7/1/2023 at 9:10 a.m. with Director of Nursing (DON) verified that the IV antibiotic (vancomycin), which was scheduled to be administered at 6 a.m., was still hanging and had not been infused. The DON revealed that the dose should have been dated and timed at the time of being hung for infusion. The DON explained that on 6/29/2023, when the infusion was started, the resident complained of pain at the IV site. The infusion was stopped, and R#4 was sent out to the hospital for further evaluation.

The DON revealed that upon return early morning on 6/30/2023, R#4 had a new PICC line in the opposite arm (left), and it was determined the resident had a blood clot in the right arm. The DON further stated that the infusion pump was supplied by the pharmacy, and the nurse had not been trained in the operation of the infusion pump. The DON was unable to program the correct infusion time into the infusion pump for the administration of the medication. After several failed attempts to program the IV infusion pump, DON stated she does not use the pump every day but could Google it or get someone to show her how to operate it. The DON further stated that she had only worked at the facility since October 2022 and was not sure if the nurse had been trained on the operation of the infusion pump.

A follow-up interview on 7/01/2023 at 1:04 p.m. with DON revealed that she was not able to locate any documentation of the staff being educated on the usage of the IV infusion pump. The DON provided all the education she had for the night agency nurse and verified that there was no education for the use of the IV infusion pump. The DON also stated that it was her expectation that medications, including intravenous medications, be administered as ordered by the physician. The DON revealed that if the medication was not administered as ordered, the physician should have been notified, and the dose should not have been documented as administered. The DON further revealed that R#4 had MRSA in the right knee, and getting her medication should have been a priority this morning.

Interview on 7/2/2023 at 10:54 a.m. with LPN DD revealed that she had worked at the facility for over a year through an agency. LPN DD stated that she had administered IV antibiotics to residents previously at the facility, but the facility did not provide her with any formal education/training for the use of the pump. LPN DD stated that her orientation at the facility consisted of training on electronic records only. Telephone interview on 7/2/2023 at 12:39 p.m. with RN II revealed that she serves as the Educational Coordinator for the facility. She stated that the licensed staff at the facility are nurses who have been hired since she had been at the facility. RN II stated that the licensed staff had been competent in the use of the IV infusion pump by verbalizing the use of the pump. She further stated that there is not always a pump available at the facility to train the staff on its operation physically. RN II revealed there had not been a need to have a representative from the pharmacy conduct an in-service on the use of the pump because there are one-two-three instructions attached to the infusion pump. In addition, RN II stated that she had not observed
nurses load the IV tubing or program the infusion pump to ensure compliance with the infusion pump operation.

The agency night nurse who worked the night of 6/30/2023 was not available for an interview during this survey.