Failure to Administer Antibiotic as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering cephalexin 500 mg oral tablets at the scheduled times as ordered by the physician. The resident, who had diagnoses including chronic obstructive pulmonary disease, systemic lupus erythematosus, and type 2 diabetes mellitus, was admitted with a bladder infection and had a physician order for cephalexin to be given four times daily. Review of the medication administration history showed that the medication was administered late on multiple occasions, sometimes more than an hour after the allowed administration window, and in one instance, two doses were given together late at night. The facility's policy required medications to be administered within one hour of the scheduled time, and deviations were to be documented appropriately. Interviews with the MDS nurse, DON, and facility pharmacist confirmed that the medication was not administered within the required time frames on several dates. The DON acknowledged that the late administration of the medication could result in ineffective treatment, and the pharmacist noted that administering doses too close together could cause adverse effects such as abdominal pain and diarrhea. The facility's failure to follow physician orders and its own policy led to the resident not receiving timely medication as prescribed.