Failure to Administer and Document Scheduled Antibiotic Doses as Ordered
Penalty
Summary
The facility failed to provide care and services in accordance with the resident's care plan by not administering scheduled doses of Cefazolin Sodium, an antibiotic, as ordered by the physician for a resident with a history of traumatic brain injury, seizures, sepsis, and MSSA infection. Specifically, the Medication Administration Record (MAR) showed that two scheduled doses were missed on separate dates, and there was no documentation in the resident's progress notes explaining the omissions or indicating that the physician was notified about the missed doses. The care plan required that medications be administered as ordered and that the resident be monitored for side effects, but these interventions were not followed. Interviews with nursing staff and facility leadership confirmed that the expected protocol for missed antibiotic doses includes notifying the provider, documenting the omission in both the MAR and progress notes, and extending the antibiotic course if necessary. However, in this case, there was no evidence that these steps were taken. The Director-in-Training also confirmed the missed doses and the lack of documentation, which did not meet facility expectations or policy requirements for implementing physician's orders and documenting care provided.