Failure to Clarify and Document IV Therapy Orders and Administration
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for a resident who had acute respiratory failure with hypoxia and hydration problems due to nausea and vomiting. Specifically, the physician's order for a one-time IV bolus was not clarified to specify the infusion duration, and licensed nurses did not thoroughly document all aspects of the IV therapy. This included missing documentation of the date and time of IV insertion, the IV catheter gauge, IV site assessment results, and the resident's response to the therapy. Additionally, the licensed nurses did not document when the physician's order was faxed to the pharmacy or whether the pharmacy received the order, which was necessary to ensure timely delivery of IV supplies. There was also a lack of documentation regarding the start and end times of the IV bags administered, including the IV bolus. These documentation gaps were confirmed during interviews and record reviews with the Director of Nursing, who acknowledged that the orders should have been clarified and that all aspects of IV therapy should have been properly recorded. A review of the facility's policy and procedure for IV therapy staff responsibilities indicated that verification and clarification of physician orders, notification of pharmacy, and documentation of all aspects of IV therapy are required. The Nursing Practice Act Rules and Regulations also outline the responsibilities of nursing staff in administering medications and therapeutic agents as ordered by a physician. The failure to follow these standards resulted in incomplete documentation and unclear communication regarding the resident's IV therapy.