Failure to Administer IV Antibiotic at Prescribed Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer an intravenous (IV) antibiotic, Vancomycin, at the rate ordered by the physician for a resident. The physician's order specified that 270 ml of Vancomycin should be infused over 2 hours at a rate of 135 ml/hr. However, during observation, the nurse set the manual flow regulator to 200 ml/hr, resulting in the medication being administered more rapidly than prescribed. The nurse acknowledged not following the physician's order and stated that IV medication rates must always be double-checked to ensure accuracy. The resident involved had multiple diagnoses, including dysphagia, heart failure, unspecified dementia, and dependence on supplemental oxygen, and was dependent on staff for all activities of daily living. The facility's policy required that IV medications and fluids be administered as prescribed and that the label be verified against the prescriber's order. The Director of Nursing confirmed that administering the medication at a faster rate than ordered constituted a medication error.