Failure to Administer All Prescribed IV Antibiotic Doses
Penalty
Summary
A deficiency was identified when a resident, who was assessed as able to understand and communicate, did not receive all prescribed doses of intravenous Meropenem as ordered by the physician for treatment of a urinary tract infection. The physician's order specified that the resident was to receive one gram of Meropenem intravenously every eight hours for seven days, totaling 21 doses. However, review of the Medication Administration Records (MARs) showed that only 19 doses were administered over the prescribed period. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the resident did not receive the full course of antibiotic therapy as ordered. The report notes that any resident with a physician order for intravenous antibiotics could potentially be affected by this practice, indicating a failure to ensure that care and treatment were provided in accordance with professional standards and physician orders.
Plan Of Correction
Resident 12 assessed with no noted concerns related to her receiving only 19 of the 21 doses of meropenem intravenously over seven days as ordered by the physician on May 20, 2025. Resident 12's physician notified of meropenem being administered intravenously for only 19 out of 21 doses from May 22, 2025 through May 28, 2025. Any resident with a physician order for intravenous antibiotics has the ability to be affected by this alleged deficient practice. A whole house audit on residents with physician orders for intravenous antibiotics was completed to ensure the correct number of doses was administered to the resident as per the physician orders. Licensed nursing staff, including agency licensed nursing staff, re-educated to administer intravenous antibiotics to residents as per physician orders for the correct number of specified doses. The Director of Nursing/designee will audit medication administration records of residents who are to receive/receiving/received intravenous antibiotics to ensure the resident is administered/receives the correct number of doses as per the physician orders weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.