Failure to Follow Medication Parameters and Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure that medication parameters were properly followed for two residents. For one resident with a history of urinary tract infection, chronic kidney disease, and low blood pressure, midodrine was ordered to be held if the systolic blood pressure exceeded 130 mmHg. However, the medication was instead held when the systolic blood pressure was less than 130 mmHg, contrary to the physician's order. Additionally, on one occasion, the medication was held without a blood pressure being recorded. This indicates that staff did not adhere to the prescribed parameters for medication administration. For another resident with multiple complex diagnoses, including sepsis and chronic respiratory failure, the facility failed to ensure the resident received an appropriate antibiotic for a urinary tract infection. The resident was started on Keflex, but subsequent urine culture and sensitivity results showed the infecting organisms were not susceptible to this antibiotic. Despite this, the antibiotic therapy was not changed, and the culture results were not communicated in a timely manner to the prescriber, as required by the facility's antibiotic stewardship policy.