Failure to Administer Ordered IV Antibiotic and Notify Provider
Penalty
Summary
Facility staff failed to administer five consecutive doses of an ordered intravenous antibiotic (Unasyn, 1.5 grams every eight hours) to a resident with a history of wound infection and a current diagnosis of cutaneous abscess of the buttock. The resident was scheduled to begin antibiotic treatment on the morning of 4/19/2025, but did not receive the first dose until 4:00PM on 4/20/2025, as documented in the medication administration record. Additionally, staff did not notify the resident's wound care medical provider about the missed doses, as confirmed by a handwritten note and staff interview. The facility's assistant administrator reported that staff are expected to contact the prescribing provider within a day's time if unable to provide an ordered medication. These actions and inactions resulted in the resident not receiving timely antibiotic therapy as ordered, and the medical provider was not informed of the missed doses.