Failure to Administer IV Antibiotics per Provider Order and Notify Provider
Penalty
Summary
A deficiency occurred when a resident with diagnoses including bacteremia, urinary tract infection, sepsis, and sacral decubitus did not receive IV antibiotic medication, Ceftaroline Fosamil, as ordered by the provider. The medication was scheduled to be administered every 8 hours for 29 days, but multiple doses were missed over several days, as documented in the Medication Administration Record (MAR) with a code indicating the medication was not given. Progress notes repeatedly referenced waiting for the medication from the pharmacy or its pending arrival, but there was no documentation that the provider was notified about the missed doses. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the expected protocol in the event of a missing medication was to notify the provider and document the action in the progress notes. However, review of the resident's medical record and progress notes did not show any evidence that the provider was informed of the missed antibiotic doses. The facility's medication policy also required provider notification in case of irregularities in medication administration, which was not followed in this instance.