Failure to Administer Ordered IV Hydration Due to Unconfirmed Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of a fistula between the vagina and small intestine, and an ileostomy, was not administered intravenous (IV) normal saline (NS) as ordered by the physician. The physician had ordered 1 liter of NS to be given intravenously for three days due to the resident experiencing diarrhea and elevated creatinine levels. Review of the Medication Administration Record (MAR) showed the order was entered but remained in a pending status and was never confirmed or administered. There was no documentation that the IV NS was given to the resident. Interviews with nursing staff and the Director of Nursing (DNS) revealed that nurses are responsible for checking and confirming pending orders in the electronic medical record system. Staff acknowledged that the order for IV NS was not processed, confirmed, or administered, and that the order was eventually discontinued. The DNS stated that if nurses are unable to start an IV, they are expected to notify the provider and document the attempts, but no documentation of provider notification was found. The incident was not recorded in the facility's incident or medication error logs.