Failure to Notify Family and Hospice of IV Fluid Order Prior to Attempted Administration
Penalty
Summary
The facility failed to immediately inform a resident's family and hospice provider of a new order for IV fluids before attempting to initiate the treatment. The resident in question was an elderly female with diagnoses including Alzheimer's Disease, dementia, and generalized anxiety disorder, who was unable to complete cognitive interviews and had significant memory deficits. She was under hospice care with a valid DNR order and a care plan that required family involvement and coordination with hospice for any changes in condition or treatment. A physician ordered IV fluids for the resident due to clinical alerts such as decreased oral intake and possible dehydration. The ADON attempted to start the IV on two occasions but was unsuccessful, resulting in a blown vein. There was no documentation of these attempts or of any notification to the resident's family or hospice prior to the procedure. The family only became aware of the IV order after noticing a bruise on the resident's arm during a visit, and subsequently learned that hospice had not been notified either. Interviews with facility staff confirmed that the family and hospice were not informed before the IV was attempted, and that documentation of the order and the attempts to start the IV was lacking. Facility policy required immediate notification of significant changes in status to both the physician and the resident's representative, as well as thorough documentation of all notifications and interventions. These procedures were not followed in this instance, resulting in a failure to uphold the resident's rights to be informed and involved in care decisions.