Failure to Administer and Document IV Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that intravenous antibiotics, Zosyn and Daptomycin, were administered according to the physician's orders for a resident diagnosed with acute osteomyelitis of the left foot and ankle and cellulitis. The resident was admitted and readmitted with these diagnoses and had intact cognitive abilities. Physician orders specified Zosyn IV every eight hours and Daptomycin IV once daily for a set period. Review of the resident's Intravenous Medication Administration Record (IMAR) revealed blank spaces on multiple dates for both medications, indicating missed doses. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that blank spaces on the IMAR meant the medications were not administered as ordered. The facility's policy required that the individual administering the medication document the administration in the resident's Medication Administration Record immediately after giving the dose. The failure to document and administer the antibiotics as ordered was confirmed through interviews and record reviews, with staff acknowledging that the missed doses could impact the resident's treatment for infection. The deficiency was identified through direct review of medical records and staff interviews, which established that the resident did not receive prescribed antibiotics on several occasions.
Plan Of Correction
F755: Pharmacy Services/ Procedure/ Pharmacist/ Records CORRECTIVE ACTION MD notified on the missed dosage of Daptomycin and Zosyn on 3/10/25 on Resident 27. MD's recommendation was to monitor adverse reaction and complication of the missed medication. Resident was assessed by RN on 3/10/25 and no new onset of acute distress noted. OTHER RESIDENTS AFFECTED IDENTIFICATION Review of the residents with IV medication orders was conducted on 3/10/2025 and no other deficient practice was noted. All IV medication orders were being administered as ordered. MEASURES AND SYSTEMIC CHANGES DON/Designee to monitor IV documentation QD x2 weeks then 2x/week x 2 weeks then monthly thereafter to ensure all IV medications are being administered as ordered by MD. Medical record will include in the daily audit the IV MAR for any missed dose of IV medications ordered by MD. DON conducted an in-service on 3/25/2025 to Registered Nurses regarding the importance of administration of IV Medication as ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. DON conducted an in-service on 3/25/2025 to Registered Nurses regarding the importance of administration of IV Medication as ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.