Failure to Administer Prescribed Antibiotic Due to Medication Unavailability and Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including acute respiratory failure, severe sepsis with septic shock, pneumonia due to MRSA, UTI, and pleural effusion, did not receive a prescribed antibiotic (Amoxicillin-Pot Clavulanate 875-125 mg) as ordered by the physician. The physician ordered the antibiotic to be administered twice daily for a possible UTI, but the medication was not available in the facility's emergency kit at the time it was needed. As a result, the nurse was unable to administer the medication and had to order it from the pharmacy, causing a delay. The medication was received from the pharmacy later that day, but documentation on the medication administration record (MAR) indicated that the resident was marked as 'unavailable' for the scheduled dose, and there was no evidence that the antibiotic was administered as ordered. Interviews with nursing staff revealed that the nurse on duty did not recall administering the medication and could not explain the documentation. Additionally, the nurse was unaware of the resident's change in condition and the need for vital sign monitoring every four hours, as ordered by the physician. Further review showed that the certified nursing assistant assigned to the resident was also unaware of the resident's earlier fever and did not take vital signs as required. Facility policies required medications to be administered safely, timely, and as prescribed, and for staff to prevent and manage medication errors. However, the failure to have the medication available, to administer it as ordered, and to notify the physician of the missed dose resulted in the resident not receiving the prescribed antibiotic for over 11 hours.