Lack of Documentation for Antibiotic Use in Post-Surgical Residents
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was free from unnecessary drugs, specifically antibiotics, for several residents who had undergone right total knee replacement. Medical record reviews revealed that multiple residents were prescribed antibiotics such as Augmentin, Cipro, and Keflex upon admission, with orders originating from their orthopedic surgeons. However, there was no documentation in the physician's progress notes to justify the continued use of these antibiotics. The nursing staff's documentation in the care plans was limited to observations of the surgical site, such as the presence of a surgical patch and edema, without further clinical justification for antibiotic therapy. Interviews with the Director of Nursing confirmed that residents typically arrived with prescriptions and instructions from their surgeons, but the facility did not provide evidence in the medical records to support the necessity of these medications. This lack of documentation affected at least three residents, as identified in the survey, and was observed during a review of eight medical records. The deficiency was based on the absence of physician progress notes justifying the use of antibiotics for these residents.