Failure to Administer IV Antibiotics at Prescribed Intervals
Penalty
Summary
Facility staff failed to administer intravenous (IV) antibiotics at the prescribed times and intervals for a resident who was cognitively intact and being treated for bilateral lower lobe pneumonia. The resident had a physician's order for IV cefazolin to be given every eight hours at 8:00 AM, 4:00 PM, and midnight, with each dose to be infused over one hour via a peripherally inserted central catheter. Review of the medication administration record revealed a pattern where the midnight dose was consistently administered four to six and a half hours late, resulting in a 13-14 hour gap between the 4:00 PM and midnight doses, and a 2-3 hour interval between the midnight and 8:00 AM doses, instead of the ordered eight-hour intervals. Staff confirmed that nurses did not administer the IV cefazolin at the prescribed times and failed to adjust subsequent doses to maintain the correct intervals. This deviation from the ordered schedule was observed on multiple occasions, as documented in the electronic health record and confirmed by the Resident Care Manager. The failure to follow the prescribed medication schedule constituted a significant medication error for the resident receiving IV therapy.