Failure to Administer Ordered Antibiotic for UTI Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with a urinary tract infection (UTI) did not receive prescribed antibiotic treatment as ordered. The resident, who had diagnoses including UTI, low back pain, muscle weakness, dementia, and depression, was ordered Cefpodoxime 200 mg, two tablets by mouth twice daily for three days. Medical record review showed that the medication was not administered as scheduled on multiple occasions due to its unavailability. Specifically, doses were missed on the evening of admission and on both scheduled times the following two days. The first dose was not given until three days after admission, and the antibiotic course was completed late. Documentation revealed that while the physician was notified on the day of admission that the medication was not available and had been ordered from the pharmacy, there was no evidence that the physician was notified on subsequent days when the medication continued to be unavailable and not administered. The DON confirmed the medication was not in the facility's contingency medication box and that pharmacy delivery was delayed. The resident experienced an episode of unresponsiveness during this period, and the physician was updated about the resident's condition, but not specifically about the ongoing lack of antibiotic administration.
Plan Of Correction
The facility will continue to ensure antibiotics are administered as ordered to treat urinary tract infections. Resident #236 continues to reside at the facility and has completed her round of ATB for UTI. Resident assessed by 4/10/2025 and was noted to be free of s/s of UTI. Immediate reeducation on transcribing orders was conducted by the DON with licensed nurse who readmitted resident #236 for hospital. An initial audit of antibiotic use in the last 30 days was conducted by DON on 4/17/2025. The DON reviewed ATB for proper administration and timely administration of antibiotics. No negative findings were noted. By 4/17/2025, the DON and or designee will reeducate licensed nurses on proper transcription of antibiotic orders, ensuring timely administration, and notifying PCP when medications are not available to be given. Weekly for 2 weeks, or as directed by the QA committee, the DON or designee will audit antibiotic orders ensuring proper transcription of orders and that they were administered timely and as prescribed. Negative findings will be corrected by notifying the practitioner and reeducating staff. Negative findings will be reported to the QA committee for review. The Administrator will ensure completion of the weekly audits. The DON is responsible for the ongoing compliance.