Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to administer antibiotics as ordered for one resident. Medical record review showed that the resident was admitted with multiple diagnoses, including anxiety disorder, depression, psychotic disorder with delusions, contractures, and cerebellar stroke. The resident was cognitively intact according to the quarterly MDS assessment. A nurse practitioner evaluated the resident for right lower extremity edema and mild pain, diagnosed very mild cellulitis, and ordered a short course of cephalexin 500 mg three times a day. The electronic physician orders reflected this prescription. However, review of the medication administration record revealed that the resident received 18 doses of cephalexin instead of the 15 doses ordered, resulting in three additional doses being administered. The infection control log confirmed the resident met criteria for antibiotic treatment, but there was no evidence that the facility identified or addressed the administration of extra doses during their antibiotic use review. An interview with the regional nurse confirmed the over-administration. The facility's antibiotic stewardship policy required monitoring of antibiotic use to prevent unnecessary or inappropriate administration, but this was not followed in this instance.