Failure to Accurately Document Antibiotic Dosage
Penalty
Summary
A deficiency occurred when the facility failed to accurately document the dosage of an antibiotic order for a resident with multiple complex diagnoses, including cerebral palsy, hydrocephalus, epilepsy, drug-induced systemic lupus, urinary tract infection, anxiety, and psychosis. The resident's Minimum Data Set indicated moderately impaired cognition. The order summary and progress notes showed conflicting documentation regarding the dosage of Meropenem prescribed for a urinary tract infection. Specifically, the order was documented as 1 mg intravenously three times a day, when it should have been 1 gram. The Medication Administration Record reflected the incorrect 1 mg dosage, although the correct 1 gram dose was actually administered. Interviews with facility staff confirmed the documentation error. The LPN responsible for transcribing the order admitted to writing the wrong dosage, and the DON acknowledged the mistake, stating that the antibiotic does not come in the documented amount. The pharmacist also verified that only 1 gram bags of Meropenem were dispensed and administered. Facility policies require accurate transcription and implementation of physician orders, as well as comprehensive assessments to inform individualized care plans, but these were not followed in this instance.