Failure to Ensure Proper IV Therapy Protocols and Documentation
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with professional standards of practice for a resident who required IV therapy. Specifically, there was no documented physician order for daily assessment, dressing changes, or a flushing schedule for the resident's Midline venous access device, despite the resident receiving IV antibiotics. Review of the Medication Administration Record (MAR) also showed no evidence of daily assessment or flushing documentation for the Midline device. During observation, a nurse flushed the Midline device prior to medication administration but based the assessment of patency on having witnessed the device's insertion the previous day, rather than on current clinical assessment or documented protocol. The Director of Nursing confirmed that appropriate orders and documentation for Midline maintenance were missing and that the nurse should have notified the practitioner for the necessary orders and documented the flushes on the MAR.