Failure to Safely Administer and Document IV Fluids
Penalty
Summary
The facility failed to administer intravenous (IV) fluids in accordance with professional standards of practice and physician orders for a resident who lacked capacity to make decisions. Specifically, the IV fluids were administered at a rate of 80 ml per hour instead of the ordered 60 ml per hour. Additionally, the IV fluid bag was not labeled with the date and time it was hung, and the administration set was not labeled as required by facility policy. When the infusion was completed, the clamp was not closed, and the empty IV container was not removed from the IV pole, leaving air in the tubing and the administration set still attached to the resident's IV access. These deficiencies were confirmed through observation, interview, and medical record review. The nurse responsible for the resident's care was unable to state when the IV solution was hung, and the Director of Nursing verified that the IV fluids were not administered as ordered and that labeling requirements were not followed. The facility's policies required IV solutions and administration sets to be labeled with date, time, and nurse's initials, and for the clamp to be closed and the container removed when empty, but these procedures were not followed in this instance.