Failure to Administer Ordered IV Antibiotic Due to Medication Unavailability and Communication Breakdown
Penalty
Summary
A resident with multiple diagnoses, including sepsis, was admitted to the facility and had a physician's order for Ceftriaxone 2GM IV daily for 12 days to treat an infection. Despite the order, the medication was not administered as prescribed, with only one dose given during the resident's stay. Clinical record review and progress notes indicated that the medication was unavailable on several occasions, and there was no evidence that the physician or pharmacy were notified about the unavailability. The medication administration record also showed missed doses, and documentation for some administrations was left blank. Interviews with nursing staff and the Director of Nursing revealed that the process for obtaining IV medications required nurses to fax orders to the pharmacy, which was not done in this case, resulting in the medication not being delivered or administered. The facility's Omnicell report showed that Ceftriaxone was present in the facility, but it was not used according to professional standards. The resident subsequently developed symptoms including a rash, grey skin color, chills, high pulse, and low blood pressure, leading to an emergent transfer to the hospital. Facility policy required medications to be administered safely and appropriately per physician's orders, which was not followed in this instance.