Failure to Notify Physician of Inability to Initiate IV Therapy
Penalty
Summary
The facility failed to notify the attending physician when nursing staff were unable to initiate an intravenous (IV) line for a resident who had a critical need for IV hydration and electrolyte replacement. The resident, who had a history of diabetes mellitus, fatty liver disease, acute kidney failure, hypertension, and cardiomegaly, was admitted with persistent nausea, vomiting, and impaired cognitive function. Laboratory results revealed critical electrolyte imbalances, including a potassium level of 2.7 mEq/L, elevated sodium, and low magnesium, prompting the physician to order immediate potassium replacement, D5W IV fluids, and magnesium supplementation. Despite these orders, the assigned RN attempted to start the IV line twice without success and then contacted a third-party IV provider, who was unable to send an IV nurse until the following morning. The RN did not inform the physician of the failed IV attempts or the resulting delay in administering the ordered IV fluids and medications. Instead, the information was only endorsed to the oncoming nurse, and no further attempts to notify the physician were documented. The physician was therefore not made aware that the resident's critical treatment could not be initiated as ordered. Interviews with nursing staff and the Director of Nursing confirmed that the facility's protocol required the physician to be notified if IV access could not be established, so that alternative interventions could be considered, such as hospital transfer or ordering a PICC or midline catheter. The facility's policy also required notification of the physician, supervisor, and oncoming shift in the event of complications with IV therapy. The failure to notify the physician of the inability to start the IV and the delay in treatment constituted a deficiency in communication and adherence to clinical protocols.