cms_GA: 6
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-03-23 | 328 | D | 0 | 1 | 6QM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and staff interviews, the facility failed to ensure residents received proper [MEDICATION NAME] treatment and care by not capping the sterile end of an intravenous (IV) tubing nor removing air from syringes and intravenous tubing. This had the potential to affect one of two residents (R) (R#37) currently receiving IV medications in a universe of 32 sampled stage 2 residents. Failure to cap the sterile end on an IV could result in a resident infection and failing to remove air from syringes or intravenous lines could result in an air [MEDICAL CONDITION] (a blood vessel blockage caused by air bubbles in the circulatory system). Findings include: Observation in R#37's room on 3/23/17 from 9:30 a.m. - 10:00 a.m. revealed Licensed Practical Nurse (LPN) (LPN KK) verbalized intention to flush R#37's right hand intravenous (IV) catheter using a 10 cc syringe of sterile normal saline (NS), However, as she moved toward the IV with the syringe, she had not expelled the visualized air from the syringe. Surveyor stopped the procedure requesting she expel the air. She held the syringe horizontally expelling liquid while the air bubble remained. She turned to resume flushing and again was asked to remove the air from the syringe, requesting LPN KK hold it vertically, syringe tip up, to examine and expel the air bubble. LPN KK did remove the air, shaking her head, offering that she was nervous being watched but can do this as she flushed the IV extension tube with the NS. LPN KK then opened the sterile IV tubing package and connected a 100 cc bag NS with 1 gram of [MEDICATION NAME] (an Antibiotic) to the IV tubing. She ran the solution through the tubing without closing clamp or turning filter upside down. LPN KK then strung the tubing through the medication pump (used to regulate the time and amount of solution administered). The pump began beeping when it was turned on. It was noted there were multiple air bubbles still in the tubing. She had difficulty clearing them. She decided to switch tubing out to a dial flow rather than use a pump. She disconnected the medication bag from the pump tubing and ran the medication through the new dial a flow tubing then connected to the resident. The clamp to the R#37's extension tubing had not yet been opened. There was air still noted in the dial a flow tubing when surveyor asked to see it before proceeding. LPN KK then disconnected from R#37's and cleared the tubing of air and reconnected but the solution would not drip after she unclamped. She unhooked the IV tubing and draped it over the IV pole without capping the exposed connection tip. The tubing was noted to swing back and forth a few times when draped over pole. LPN KK cleaned tip with alcohol and covered with the cap after surveyor pointed her over sight out to her as she went to leave R#37's room. Examination of Facility Policy Administration of Infusion Therapy, Procedure for Continuous or Intermittent Infusion last reviewed 9/27/16 specified in step 7: Remove the tubing from the package and close the roller clamp. Step 10: Hang the bag (with the previously inserted tubing) on the pole, squeeze the drip chamber to establish the proper fluid level (1/2 - 2/3 full). Turn the filter upside down, open the roller clamp, and prime system of air. Step 12: Remove air from normal saline flush syringe (to flush the infusion access device.) Step 16: Disconnect administration set from injection valve and place sterile cap over leur-lock end of IV tubing. Interview of LPN KK at 10:00 a.m. revealed she was upset with myself and should have assured air was removed from syringe and tubing before proceeding. She acknowledged that capping the connection tip would protect from contamination. She further revealed she has had training in IV care but does so infrequently. During the 11:00 a.m. Interview on 3/23/17 of the Director of Nursing (DON), revealed LPN KK should have followed the IV procedures and My biggest concern is in regard to (LPN KK's) lack of air removal from the syringe and IV tubing. The DON revealed the facility does not perform competencies on nurses regarding IV medication administration but would see LPN KK is re-educated. However, at 12:30 p.m.,, the DON provided a copy of a 3/1/2016 Medication pass observation report performed by an RN Pharmacy Consultant of LPN KK performing a Normal Saline IV flush. The document did not include a check off of the expected steps of the observed IV push procedures nor was the use of intermittent IV med bag infusion or tubing care documented as part of the observations performed on 3/1/16. | 2020-09-01 |