Failure to Develop Care Plan for IV Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the use of intravenous (IV) fluids for one resident. Medical record review showed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 6, was admitted and subsequently received orders for Dextrose Intravenous Solution 5% and Dextrose Intravenous Solution 5% with multivitamin. The IV fluids were administered as ordered, with documentation confirming administration on specific dates. Despite the administration of IV therapy, there was no evidence in the resident's medical record that a care plan was developed to address this intervention. This was verified during interviews with both an RN and the DON, who acknowledged the absence of a care plan for the resident's IV therapy. The lack of a documented care plan meant that the resident's individual needs related to IV therapy were not formally identified or addressed in the care planning process.