Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Three residents receiving intravenous (IV) antibiotics experienced significant medication errors due to failures in medication order clarification, unauthorized changes to physician orders, and missed doses. One resident was admitted with a complex medical history including osteomyelitis, bacteremia, and acute kidney injury, and had a hospital discharge order for IV cefepime. Staff did not recognize a dosing error in the discharge order and entered it incorrectly into the facility's system. Subsequently, a registered nurse changed the order without consulting a physician, resulting in discrepancies between the hospital discharge order, the facility physician's order, and the nurse's revised order. The resident missed three doses of IV antibiotics over four days, and there was no documentation that the physician was notified of these missed doses. Another resident with multiple chronic conditions, including pneumonia, MRSA infection, and diabetic foot ulcer, had a physician order for IV vancomycin. The medication administration record (MAR) showed that a scheduled dose was not administered, and there was no documentation that the physician was notified of the missed dose. Additionally, a change in the administration time was communicated to the infectious disease office, but subsequent missed doses were not reported to the physician. A third resident with diagnoses including bacteremia, osteomyelitis, and diabetes was prescribed IV ceftriaxone via a PICC line. The MAR indicated that a scheduled dose was not administered because the resident was away from the facility for a physician appointment. There was no documentation that the physician was notified of the missed dose, and the facility physician confirmed that they were not made aware of the missed administration. In all cases, the facility failed to ensure that IV antibiotics were administered as ordered and that physicians were notified when doses were missed.
Removal Plan
- Review R203's medication orders for accuracy and availability and notify Infectious Disease (ID) of missed doses.
- Audit all residents on antibiotics and verify their medications are available and being administered.
- Educate nursing staff on the facility's policy for administering medication per physician orders and what to do when medications are unavailable.
- Educate nursing staff on confirming pharmacy orders with the physician and that nurses may not change medication orders without physician approval.
- Initiate audits to ensure admission orders are transcribed correctly and have been received from the pharmacy.