Missed IV Vancomycin Doses and Lack of Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, contractures, muscle weakness, and a surgically closed wound infection of the left hip, was admitted with a physician's order for daily intravenous Vancomycin to treat the wound infection. The resident was severely cognitively impaired and required extensive assistance with activities of daily living. According to the medication administration record, the resident missed three scheduled doses of Vancomycin on separate days, with no documentation provided for the missed doses. There was no evidence that the physician was notified about the missed doses or that any laboratory tests were drawn as a result. Staff interviews confirmed that the expectation was to document any missed medication doses and notify the provider, but this did not occur. The lack of documentation and provider notification for the missed antibiotic doses constituted a failure to provide treatment and care according to physician orders and facility policy.