Antibiotic Administered Without Documented Clinical Indication
Penalty
Summary
A resident with multiple chronic conditions, including multiple sclerosis, COPD, and dementia, was assessed by nursing staff after exhibiting labored breathing, lethargy, increased respiratory rate, diaphoresis, and other abnormal vital signs. The nurse notified the certified registered nurse practitioner (CRNP), who ordered a one-time dose of Ceftriaxone, a broad-spectrum antibiotic, to be administered intramuscularly, along with laboratory tests and a chest x-ray. The resident received the antibiotic prior to the availability of laboratory or imaging results. The clinical record did not contain any documentation from the physician or CRNP providing a diagnosis or clinical indication for the initiation of the antibiotic therapy. There was no documented clinical rationale for starting the antibiotic before receiving the results of the ordered tests. The Director of Nursing confirmed that no such documentation existed in the resident's record, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.