Failure to Document IV Antibiotic Administration
Penalty
Summary
A resident with acute osteomyelitis of the right tibia and fibula and a MRSA infection was admitted to the facility and had a physician's order for daptomycin-sodium chloride IV solution to be administered every evening for a left lower extremity wound infection. On April 5, 2025, the Medication Administration Record (MAR) did not indicate that the ordered dose of the IV antibiotic was administered. Progress notes for the same date stated that the resident was currently receiving an IV antibiotic, but there was no documentation confirming the administration of the specific dose as required. During an interview, the DON confirmed that the missing documentation on the MAR made it difficult to verify whether the IV antibiotic had been given. The facility's policy requires that medications be administered as prescribed and that the person administering the medication records the administration on the MAR/eMAR immediately after giving the medication. The policy also states that the MAR/eMAR should be reviewed at the end of each medication pass to ensure all necessary doses are documented, and that no staff should leave duty without recording medication administration. In this instance, the required documentation was not completed, resulting in a significant medication error.