Failure to Administer Ordered IV Antibiotic Due to Medication Ordering Process Lapse
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered medication as required. The resident, who had multiple diagnoses including sepsis, COPD, asthma, anemia, endocarditis, hypothyroidism, hyperlipidemia, and hypertension, was admitted with an order for Ceftriaxone 2GM IV daily for 12 days to treat an infection. Clinical record review and the medication administration record (MAR) showed that the resident received only one dose of Ceftriaxone during their stay, despite the medication being available in the facility’s Omnicell system. Progress notes repeatedly documented that the medication was unavailable on several days, and there was no documentation of administration on other days when it was due. Interviews with nursing staff and the Director of Nursing revealed that the process for ordering IV antibiotics required nurses to fax the orders to the pharmacy, and this step was likely missed, resulting in the medication not being delivered or administered as ordered. The DON confirmed that the medication was present in the facility but was not provided to the resident as required. Facility policy states that medications are to be administered safely and appropriately per physician order, but this was not followed in this instance.