Failure to Ensure Safe IV Antibiotic Administration and Documentation
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) antibiotics for a resident who required long-term IV therapy following hospital discharge. Upon the resident's re-admission, there was a lack of timely physician orders for the prescribed IV antibiotics, resulting in missed doses of Piperacillin-Tazobactam (Zosyn) and Daptomycin. The facility's staff did not implement a process to ensure that the necessary orders were obtained and that the antibiotics were administered as scheduled, leading to several missed doses over multiple days. Additionally, the facility did not adhere to its own policies and professional standards regarding the administration and documentation of IV medications. There were multiple instances where staff documented the administration of IV antibiotics either late, by unqualified personnel, or by staff who were not present in the facility at the time the medication was scheduled to be given. Some doses were documented as administered days after the scheduled time, and in some cases, the documentation was completed by staff who were not on duty during the relevant shifts. Furthermore, there were periods when no registered nurse (RN) was scheduled to be present to administer the IV antibiotics, resulting in additional missed doses. The facility also failed to provide adequate education and training to all licensed staff responsible for administering IV medications, including proper care and flushing of the resident's peripherally inserted central catheter (PICC) line. Documentation showed that the PICC line was not flushed according to standards of care and physician orders, and there was no evidence of specific training provided to staff on IV therapy procedures. These failures were determined to have caused, or were likely to cause, serious harm to the resident, resulting in the citation of Immediate Jeopardy under F694 for Parenteral/IV Fluids.