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Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to label Intravenous (IV) fluid bags and/or tubing for three (3) of ten (10) sampled patients selected for review. In addition, the distal tip of the IV line for Patients #2 and #6 was uncovered and not capped with a sterile adapter per facility policy.

The facility also failed to implement physician orders for wound care for one (1) of ten (10) patients (Patient #2). The facility failed to apply a Mepilex dressing to Patient #2's pressure ulcer as ordered by the patient's physician on 04/08/19.

The findings include:

Review of the facility's "Labeling Standards," last reviewed 12/29/15, revealed all drug containers would be labeled in compliance with state and federal requirements. According to the policy, all medication labels would include a beyond use date and/or time. In addition, all intravenous admixture labels would include: name and location of the patient; beyond use date and/or time; infusion rate; initials of the person who made the admixture; and date and time the medication was prepared. Further, all intravenous solution labels must include the time/date due and directions for use.

A review of the "IV Drug Administration Guidelines," reviewed 12/19/15, revealed all sterile IV dosage forms had a 24-hour beyond use date once penetration with an IV line occurred.

Review of the Lippincott Nursing Procedure Text Book revealed when reusing secondary solution tubing, staff were required to close the clamp on the tubing, remove the needleless adapter, and then replace with a new sterile adapter.

1. Review of Patient #2's medical record revealed the facility admitted the patient on 04/01/19 with pneumonia. On 04/08/19 at 3:00 PM, Patient #2 was observed in bed with IV fluids infusing (5% Dextrose in water) at 30 cubic centimeters (cc) per hour. Observation revealed neither the IV bag of fluids, nor the IV tubing, was labeled with the patient's name, room number, or the date and time the IV was initiated as required by the facility's policy.

Further review of Patient #2's medical record revealed a physician's order for a Foam Dressing with a border to be applied to the patient's left buttock. However, observation of a skin assessment on 04/08/19 at 3:00 PM revealed there was no dressing to the Stage 2 pressure ulcer to the patient's buttock.

Interview with Patient #2's nurse, Licensed Practical Nurse (LPN) #1, on 04/08/19 at 1:35 PM revealed the LPN was not aware Patient #2's Mepilex dressing (absorbent foam dressing) had been removed. According to LPN #1, the certified nurse aide (CNA) provided incontinence care and failed to inform LPN #1 that the Mepilex dressing had been removed.

Interview with CNA #1 on 04/09/19 at 1:50 PM revealed she informed LPN #1 that Patient #2's Mepilex dressing had to be removed because it was soiled. She stated CNAs could remove the dressing, but could not replace the dressing. CNA #1 stated he told LPN #1 that the dressing needed to be reapplied, but, "I guess he must have forgotten."

2. Review of Patient #3's medical record revealed the facility admitted the patient on 04/07/19 due to Chest Pain, Chronic Obstructive Pulmonary Disease (COPD), and Pneumonia, with orders for Levaquin (an antibiotic).

Observation of Patient #3 on 04/08/19 at 4:20 PM, revealed the patient was in a chair with his/her IV clamped and disconnected. Observation revealed an IV bag of normal saline (250cc) was hanging at the patient's bedside with the distal tip of the tubing uncovered, lying on the IV pump without a sterile cap as required by the facility's policy. Further observation revealed the IV bag/tubing was not labeled with the patient's name/room number and was not dated or timed by the nurse as required per facility policy/protocol. Interview with the Nurse Manager present during the observation revealed the normal saline was not changed and was only used to flush IV sites.

3. Review of Patient #6's medical record revealed the facility admitted the patient on 04/07/19 with aspiration pneumonitis. Observation of the patient on 04/08/19 at 3:10 PM, revealed the patient was seated on his/her bedside, sponge bathing. Further observation revealed the patient's IV line was disconnected and the distal tip of the line was lying on the IV pump uncovered without a capped sterile adapter. Further observation revealed the patient's IV bag and line were not labeled with the patient's name, room number, or the date and time the IV fluid was initiated. According to Patient #6, the IV line had been disconnected so the patient could bathe.

Continued interview with LPN #2 on 04/08/19 at 3:20 PM revealed she was responsible for providing care for Patient #6 and stated the patient received Levaquin (antibiotic) daily via the IV. However, LPN #2 stated she had no knowledge regarding who initiated IV fluids for Patient #6, how long the IV bag/tubing had been hanging, or why the bag and tubing were not labeled with the patient's name, room number, and date and time the medication was initiated. According to LPN #2, the patient's IV had been disconnected so Patient #6 could bathe; however, she gave no explanation why a new sterile adapter had not been applied to the open IV line as required by facility policy/protocol.

Interview with the Infection Control Nurse on 04/08/19 at 4:00 PM and the Nurse Manager on 04/10/19 at 3:50 PM revealed IV bags should always be labeled with the patient's name, room number, and dated/signed by the nurse. The Infection Control Nurse gave no explanation why IV bags/tubing for Patients #2, #3, and #6 had not been labeled/dated.