Failure to Notify Physician of Unsuccessful IV Insertion
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of an unsuccessful attempt to insert a midline intravenous (IV) line for a resident with a history of stroke and dementia. The resident, who was rarely or never understood, had a positive urine culture and possible pneumonia, and was ordered to receive IV antibiotics after refusing oral medications. The physician's order specified the insertion of a midline IV and administration of cefepime. However, the nursing note documented that the IV could not be inserted due to the resident's combative behavior, and only the resident's representative was notified. Nurse #3, who was present during the failed IV insertion, informed the Unit Manager (UM) but did not directly notify the on-call Nurse Practitioner (NP), assuming the UM would do so. The UM, in turn, did not notify the NP, believing it was Nurse #3's responsibility. As a result, the NP was not informed of the failed IV insertion until the following day. The delay in notification meant the NP was not immediately aware of the resident's inability to receive the ordered IV antibiotic treatment.