Failure to Administer IV Antibiotics and Provide PICC Line Care per Physician Orders
Penalty
Summary
Staff failed to follow physician's orders for a resident who was readmitted with sepsis and a urinary tract infection. The physician's orders required administration of two IV antibiotics—Ertapenem once daily for 14 days and Merrem three times daily until a specified date—as well as PICC line care, including flushing the line before and after each antibiotic dose. Review of the medication administration record revealed missed documentation for several doses of both antibiotics and multiple instances where PICC line care was not documented as provided. Interviews with a licensed nurse and the Director of Nursing confirmed that there were missed entries for medication administration and PICC line care, and that if it was not documented, it was considered not given. Facility policy required implementation of physician orders and accurate documentation of all medications and treatments. The lack of documentation and missed care placed the resident at risk for delayed healing and complications related to the PICC line.