Failure to Administer IV Fluids as Ordered
Penalty
Summary
Facility staff failed to administer intravenous fluids (IVF) as ordered by the physician for a resident who was admitted with a left tibia fracture and acute kidney failure. The resident's physician had ordered 0.45% Normal Saline to be administered at a rate of 100 mL/hour for 24 hours for hydration. However, observations revealed that the IVF was initially being administered at a rate of 50 mL/hour instead of the prescribed 100 mL/hour. This discrepancy was identified during an observation and confirmed through interviews and record review with nursing staff. The resident was noted to have severe cognitive impairment and required significant assistance with daily activities. The error in IVF administration was acknowledged by both the RN and the DON, who confirmed that the fluids were not being given at the correct rate as per the physician's order. The facility's medication administration policy required medications and treatments to be administered as prescribed to ensure compliance with dose guidelines, which was not followed in this instance.