Failure to Facilitate Resident Choice in Medication Administration Timing
Penalty
Summary
A resident with an intact cognitive status and a diagnosis of right knee prosthesis infection requiring daily intravenous (IV) Ertapenem requested that the timing of her antibiotic infusion be changed from late at night to earlier in the evening. The resident reported that the current schedule required her to be awakened at 11 p.m. for the infusion and again an hour later when it was completed, which disrupted her sleep. She communicated her preference to nursing staff, specifically to an LPN and an RN, but neither initiated the facility's standard process for medication change requests, which involves completing a Situation Background Assessment Recommendation (SBAR) report. Both the LPN and RN informed the resident that the medication time could not be changed without provider or pharmacist approval, but did not document or escalate the request as required. The nurse practitioner confirmed that the antibiotic administration time could have been adjusted to the resident's preference and was unaware of the request due to lack of communication via SBAR. The director of nursing stated that anyone could complete an SBAR for such requests, but no SBAR was found for this resident. The facility also failed to provide a policy regarding resident choices when requested. As a result, the resident continued to receive the medication at the undesired late hour.