Failure to Timely Implement Physician Order for IV Fluids
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of a physician’s order for IV fluids for one resident. The resident had multiple significant diagnoses, including age-related osteoporosis, hypertensive heart and chronic kidney disease with heart failure stage 3, COPD, type 2 diabetes mellitus, multiple right-sided rib fractures, fractures of the right ulna styloid process and shaft of the right radius, and protein-calorie malnutrition. A handwritten physician order dated 02/17/26 directed that 1 liter of normal saline be administered intravenously at 100 cc/hr. This order was signed by an LPN on 02/18/26. The MAR/TAR for 02/18/26 showed an order for 0.9% normal saline IV, 1 liter every 24 hours for dehydration, to run at 100 ml/hr starting at 6:30 p.m., and documentation indicated that an RN initiated a peripheral IV in the left antecubital space at that time with normal saline running at 100 ml/hr. Interviews revealed that the IV order was not carried out in a timely manner after it was received. The RN who started the IV stated that two nurses before her had refused to hang the IV and that she was told by the DON that they had to hang it, while the DON denied instructing any nurse to start the IV or having knowledge of nurses refusing to do so. The DON confirmed that the IV infusion order was not initiated timely on 02/18/26 and stated that the RN had all day to start the IV and administer the fluids per the physician’s order. The LPN who signed the order reported she might have taken the IV order and believed the dayshift nurse was to start the IV. The Interim DON confirmed that timely IV administration would be within a few hours of receiving the order and that this did not occur. The ADON also confirmed the IV infusion order was not initiated timely and denied knowledge of instructing a nurse to start the IV or of any refusals. The facility’s Physician Orders policy stated that the nurse who takes the physician order is responsible for executing it or providing a safe hand-off to the next nurse, which did not occur as required in this case.
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