Failure to Administer Ordered IV Fluids as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to administer IV fluids according to the physician’s order for a resident receiving treatment for dehydration. The resident, cognitively intact and admitted with chronic pain, had a verbal order from the Medical Director for 0.9% sodium chloride IV solution at 80 mL/hr for a total of 2 liters. This order was transcribed onto the MAR, which showed the IV fluids as administered on multiple shifts from late February into early March, with one documented refusal on a night shift. The MAR entries indicated that the ordered sodium chloride IV fluids were being given as prescribed. On March 1, MAR documentation by nursing staff showed that instead of 0.9% sodium chloride, D5NS (5% dextrose in 0.9% sodium chloride) was infusing because the ordered 0.9% sodium chloride was reportedly unavailable. An observation that afternoon confirmed a one‑liter bag of D5NS infusing through a saline lock in the resident’s forearm, with the bag labeled only with a date and no initials. The resident reported receiving IV fluids for dehydration, stated she did not like to drink, and believed she had been receiving IV fluids all day, but was unable to identify the type of fluid. In interviews, Nurse #2 stated she received report that the IV fluids had completed during the night and that a new bag had been hung just before shift change, but she did not visually inspect the IV bag or tubing during her shift and could not confirm which fluids had been given. She acknowledged she was required to verify the fluid type, amount infused, and flow rate against the provider’s order but did not do so. The Medical Director reported he had not been informed that D5NS was administered instead of the ordered 0.9% sodium chloride and stated he expected staff to notify a provider of any medication administration issues. The DON stated she was not aware that the wrong IV fluid had been administered or that staff had documented using D5NS due to unavailability of 0.9% sodium chloride, and indicated staff were expected to administer IV fluids as ordered and to use pharmacy‑supplied, resident‑specific labeled fluids.
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