Failure to Clarify and Document IV Fluid Infusion Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV fluids for a resident who required IV hydration therapy. The resident’s care plan, revised on 1/29/26, identified a need for IV fluids/medications related to hydration therapy with an intervention to provide IV fluids as ordered. However, the physician order dated 1/1/26 for Dextrose 5% IV solution specified “Use 2 liter intravenously one time only for dehydration for 2 days” but did not include an infusion rate. This incomplete order was transcribed onto the January 2026 MAR with the same missing infusion rate, and the MAR documented that the IV fluid was administered at 6:32 p.m. without any documentation of the rate. Progress notes dated 1/2/26 stated that D5 normal saline IV fluids were infusing and continuously running, but again did not include the infusion rate. During surveyor interviews on 3/4/26, an RN stated that they followed the order and that staff “normally” run IV fluids at 75 mL per hour at the facility, but could not recall how much IV fluid the resident actually received. The DON initially stated that it was not possible that IV fluids were administered without a prescribed rate and later reported having spoken with a pharmacist who said IV fluid orders are based on patient weight, but no documentation of this was provided. The MAR showed that an LPN administered the D5 IV fluid on 1/1/26; when questioned, the LPN was unsure of the exact order, could not recall the infusion rate, and did not remember clarifying the incomplete order with the physician. The LPN stated that they would call a physician if there was a question about an order but did not recall doing so in this case and was not aware of any standing orders for IV fluids. The facility’s physician orders policy required that medication orders include route, dose, time, and frequency, and that verbal/telephone orders be documented in the electronic medical record, but there was no evidence that the IV fluid order was clarified or completed to include an infusion rate prior to administration.
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