Failure to Administer IV Medication at Prescribed Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer intravenous Vancomycin to a resident at the prescribed infusion rate. The resident, who had diagnoses including urinary tract infection (UTI) due to MRSA, gout, and a right femur neck fracture, was ordered to receive Vancomycin 750 mg in 250 ml normal saline over 90 minutes every 24 hours. During observation, the nurse was found to be administering the medication by gravity without a dial-a-flow infusion set, which is required by facility protocol to control the infusion rate. The nurse was unable to confirm the infusion rate and acknowledged that the medication might not be completed within the prescribed 90 minutes. Further review showed that the Vancomycin infusion was still ongoing well past the intended completion time. The facility's policies require that IV medications be administered as prescribed, including the use of appropriate equipment to ensure correct infusion rates. Both the DON and the pharmacist confirmed the importance of adhering to the ordered infusion rate and the facility's protocol, which was not followed in this instance.