Failure to Administer IV Vancomycin at Ordered Rate and Without Proper Labeling
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to administer intravenous (IV) Vancomycin to a resident according to the physician's order and pharmacy instructions. The medication was ordered to be infused at a rate of 150 ml/hr, but the RN administered it at 250 ml/hr. The RN was aware of the correct rate but intentionally set the infusion at a higher rate due to the resident's combative behavior and the unavailability of an IV pump. The RN did not notify nursing management of this deviation from the order and was not fully aware of the specific risks associated with rapid Vancomycin infusion. The resident involved had multiple medical conditions, including COPD, muscle weakness, depression, difficulty walking, a right great toe amputation, a lower left leg open wound, and a peritoneal abscess. The resident also had severely impaired cognition, was disoriented, and exhibited behaviors such as wandering and resistance to care. At the time of the incident, the resident was receiving Vancomycin for an infection, and the medication was observed being administered at the incorrect rate. The IV bag in use did not have a proper pharmacy label with the resident's name, dose, and administration instructions, as required by facility policy. Interviews with facility staff confirmed that the medication should have been administered using a pump at the prescribed rate, and that all IV medications must have a pharmacy label with complete information. The nurse administering the medication did not follow these protocols, and the deviation from the ordered administration rate was considered a significant medication error by the medical director and pharmacy. The facility's policies require medications to be administered as prescribed, with verification of the label and adherence to the seven rights of medication administration.