Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics as ordered for a resident admitted with sialoadenitis and bacteremia. The physician's order specified cefazolin sodium 2 grams IV every eight hours for parotitis and sepsis. Documentation showed that only one dose was administered, and two scheduled doses were missed. The medication administration record (EMAR) indicated that the 6:00 AM dose was documented as given but was actually administered late at 10:12 AM, while the 10:00 PM and 2:00 PM doses were not administered at all. The Omnicell dispensing record confirmed the timing of the medication removal, and progress notes reflected the resident's arrival and the inability to administer the antibiotics as ordered. Interviews with facility staff, including the former DON and the interim DON, confirmed the missed and late doses, as well as improper documentation. The former DON acknowledged not administering the 10:00 PM dose due to personal circumstances and failing to inform the administrator. The resident's representative reported that the resident did not receive the prescribed antibiotics until mid-morning the following day and that no further doses were given, leading the family to request a transfer to the hospital for proper administration. Facility policies required timely and accurate medication administration, which was not followed in this case.