Failure to Inform Resident and Family of IV Therapy and Alternatives
Penalty
Summary
The facility failed to ensure that a resident and her family member were fully informed about the initiation of intravenous (IV) fluid therapy, including the risks, benefits, and alternative treatment options. The resident, who had severe cognitive impairment as indicated by a BIMS score of 6, was started on Dextrose Intravenous Solution 5% per physician orders. Medical record review showed no documentation that the family member was notified about the IV therapy, its potential effects, or provided with alternative options prior to administration. During interviews, the family member confirmed that she was not informed about the IV fluids and only became aware of the therapy upon visiting the resident. Nursing staff verified that the IV fluids were administered and acknowledged the lack of documentation regarding the indication for the therapy and the absence of family notification. The Director of Nursing was made aware of these findings and acknowledged the deficiency.