Failure to Administer Correct IV Solution per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, acute kidney failure, and malnutrition was administered the incorrect intravenous (IV) solution, contrary to the physician's order. The resident was at risk for dehydration and had an order for Sodium Chloride 0.45% IV at 75 ml/hr, which was later changed to Dextrose 5% (D5W) at 65 ml/hr due to hypernatremia and tachycardia. Despite this change, the resident was given D5 ½ NS (Dextrose 5% in 0.45% Sodium Chloride) instead of the ordered D5W, as the correct solution was not available in stock. The LPN who administered the IV solution believed it was correct after confirming with an RN, but did not verify the updated order or contact the provider for clarification when the correct solution was unavailable. The error was not identified during the shift change, as the incoming LPN did not verify the IV solution due to arriving late and only received a verbal report. The oncoming nurse checked the IV site but not the fluid, and did not take vital signs upon assuming care. The incorrect IV solution continued to be administered until the resident was found to be lethargic and tachycardic, prompting further assessment and eventual transfer to the emergency department. Multiple staff interviews revealed that the facility's protocol for verifying IV solutions during shift change and monitoring IV sites every two hours was not followed. Facility documentation and staff interviews confirmed that the wrong IV fluid was administered and that there was a failure to verify the correct solution at multiple points, including by the supervising RN and the Director of Nursing. The policies required staff to follow physician orders for IV fluids and to monitor IV sites regularly, but these procedures were not adhered to, resulting in the administration of an incorrect IV solution to a resident with significant medical needs.