Failure to Ensure Timely IV Fluid Administration
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) access care according to its own policies and procedures for one resident. The resident, who had multiple diagnoses including hypertension, diabetes mellitus type 2, muscle weakness, gait abnormalities, heart failure, and asthma, was admitted with an order for Dextrose 5% IV solution to be infused at 50 ml per hour over 20 hours for hydration. On observation, the IV bag was found hanging with approximately 550 ml remaining, not infusing, and the bag was dated two days prior. The IV was connected to the resident's right forearm, but no drops were observed in the drip chamber, indicating the infusion was not running as ordered. A family member reported that the IV had not been infusing for at least 40 minutes and mentioned previous issues with the IV tubing. The Registered Nurse Supervisor was unaware of the IV order and had to check the resident's chart to confirm the order. Upon further interview, the nurse acknowledged forgetting about the IV order despite being informed by the prior shift. The facility's policy requires licensed nurses to be knowledgeable about the length of time needed to administer IV medications, to assess the IV site and system, and to review provider orders for correct administration, all of which were not followed in this instance.