F0694

D

Failure to Document and Monitor IV and Midline Therapy per Professional Standards

New Rochelle, New York Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to ensure parenteral fluids were administered consistent with professional standards of practice for one resident who received IV therapy for bradycardia and later for hypernatremia. The facility’s IV policies required verification of provider orders, proper labeling and setup, monitoring of infusions, and documentation of IV insertion, site assessments, and dressing and tubing changes, as well as every-shift monitoring for signs of infection or infiltration. Despite these requirements, the resident’s medical record lacked documentation of the date and time of IV insertions, site assessments, the resident’s tolerance, and verification of device placement for both a peripheral IV and a midline catheter.

For the first IV course, a physician ordered 0.9% sodium chloride at 75 cc/hr for three doses to support hemodynamic stability after bradycardia was noted. A nursing note confirmed a peripheral line order, but there was no documentation of when or where the IV was inserted, nor any site assessment or tolerance. The MAR showed two administrations of the ordered IV solution across two shifts, but there was no documented administration or assessment during the intervening shift. Additionally, there was no documentation that the resident was evaluated to determine whether the IV access device should be maintained or removed after completion of the ordered IV therapy. A later nursing note documented that the peripheral IV in the left hand became dislodged and was bleeding, at which time the line was removed and the site cleaned and dressed.

For the second IV course, following lab results showing elevated sodium, a physician ordered a midline via an IV vendor and 0.45% sodium chloride at 50 cc/hr every shift for nine doses for hydration. A nurse documented two unsuccessful peripheral IV attempts and that a midline was ordered, and a later note documented that IV fluids were started, but there was no documentation of the midline placement, including date and time, site assessment, resident tolerance, or verification of insertion. The MAR showed that the IV solution was administered over multiple shifts, but nursing notes from this period did not consistently document assessments and monitoring of the IV site. The notes inconsistently described the device as a peripheral line in the left arm or left hand and as a midline in the left upper arm. During interviews, an RN and the DON acknowledged that documentation of IV placement and ongoing assessment was missing, and the NP described the ordering process and expectation that providers be notified upon completion of IV therapy for reevaluation of treatment or removal of the access device.