IV Antibiotic Administered at Incorrect Rate
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including heart failure, dementia, and dependence on supplemental oxygen, was administered an intravenous antibiotic (Vancomycin) at a rate faster than prescribed by the physician. The physician's order and the IV medication label specified that the Vancomycin should be infused at 135 ml/hr over two hours. However, during an observation, it was found that the registered nurse manually set the flow regulator to 200 ml/hr, contrary to the prescribed rate. The nurse acknowledged the error during an interview, stating that the medication should have been administered at the ordered rate to prevent potential side effects. The Director of Nursing confirmed that licensed nurses are required to follow physician orders regarding medication administration, including the rate. Facility policy also requires that medications be administered as prescribed and that the label be verified against the order. The error was identified during a random observation and confirmed through interviews and record review.