Failure to Administer Ordered Probiotic
Penalty
Summary
A deficiency occurred when a resident with dementia, Alzheimer's disease, anxiety, depression, and pneumonia was prescribed a probiotic (Saccharomyces boulardii) to be administered daily while receiving an antibiotic (Doxycycline Hyclate) for an upper respiratory infection. The physician's order specified the probiotic was to be given for a set period, and the medication administration record (MAR) was initialed by two nurses indicating the probiotic was administered. However, interviews and pharmacy records revealed that the prescribed probiotic capsules were never actually given to the resident, as the full supply was returned to the pharmacy unopened. Further investigation showed that the responsible party did not provide any probiotics to the facility, and the nurses involved either could not recall the order or were unavailable for comment. The resident subsequently developed a yeast infection, for which a medicated vaginal cream was ordered. The discrepancy between the MAR documentation and the unused medication was not explained by facility leadership, and there was no evidence that the probiotic was administered as ordered.