Failure to Administer and Document IV Fluids per Policy
Penalty
Summary
The facility failed to provide necessary treatment and services related to the administration and documentation of intravenous fluids (IVF) for one resident. According to the facility's policy and procedure (P&P) for intravenous administration, staff are required to monitor residents receiving continuous fluids for signs of complications, document specific details of the infusion, and notify the provider of any issues. For the resident in question, a physician's order was received for STAT labs and normal saline IVF at a specified rate. Although a nurse documented that the orders were noted and carried out, there was no evidence in the resident's progress notes or medication administration record (MAR) that the IVF was actually administered or that the IV site was monitored as required. Additionally, there was no documentation that the physician was notified if the IVF was not given. Further review revealed that the required physician's order for the IVF was missing from the resident's order summary and MAR. Interviews with nursing staff confirmed the lack of documentation regarding the insertion of the IV, administration of fluids, and monitoring of the IV site. There was also no record of the removal of the normal saline IVF from the facility's emergency kit, as required by protocol. Both the facility's administrator and director of nursing acknowledged these findings, and the pharmacy supplying the IV fluids confirmed that no documentation was provided by facility staff to show the IVF was removed from the emergency kit for the resident.