Failure to Accurately Administer and Document Ordered IV Sodium Chloride
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration and documentation of an IV order for Sodium Chloride 0.9% for a resident with dementia, chronic kidney disease stage 3, anemia, and bradycardia. The resident’s care plan identified risk for infection related to compromised medical condition, with an intervention to administer medications and/or antibiotics per MD orders. The physician’s order summary showed an order for Sodium Chloride 0.9% at 50 ml/hr IV every shift for hydration for 2 days, one liter total, with a start date of 03/25/26 and end date of 03/27/26. RN B reported that on 03/25/26 during the 2 p.m. to 10 p.m. shift, he started the IV at the beginning of his shift and removed it before clocking out after the resident had removed her IV, and he did not reinsert it. The March 2026 eMAR reflected that the Sodium Chloride 0.9% had been signed off as administered on 03/26/26 by LVN A during the 10 p.m. to 6 a.m. shift. In an initial interview, LVN A stated she entered the resident’s room at 3:00 a.m. to administer an IV bag of Sodium Chloride 0.9% and returned at 3:00 a.m. to remove it, and that she signed it as administered on the eMAR. However, review of surveillance footage showed LVN A entering the resident’s room at 3:38 a.m. without an IV bag and exiting at 3:39 a.m. In a later telephone interview, LVN A stated the order was for one liter of Sodium Chloride 0.9% to run continuously until finished, that each shift’s charge nurse was supposed to check the IV, and that when she entered the room around 3:30 a.m. she did not see the IV running and assumed the order had been completed. She acknowledged she was not sure if she had signed it off and that her earlier account to the surveyor was incorrect. The DON confirmed the order was for one bag of Sodium Chloride 0.9% to run continuously until completed and that each shift’s charge nurse was to check the IV and sign the eMAR once checked, and stated that LVN A should not have signed off the Sodium Chloride order because it was not being infused. The facility’s Medication Administration policy required medications to be administered as ordered by the physician.
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