Failure to Monitor and Document Antibiotic Side Effects
Penalty
Summary
Facility staff failed to monitor and document the side effects of antibiotic therapy for seven out of eleven residents who were receiving antibiotics. These residents had various medical conditions, including tuberculosis, respiratory failure, pneumonia, aortic valve stenosis, osteomyelitis, COPD, post-liver transplant care, and urinary tract infections. Physician orders for antibiotics such as Levofloxacin, Ethambutal, Linezolid, Vancomycin, Ciprofloxacin, Ceftriaxone, Cefdinir, and Bactrim were present in the residents' records. Interviews with nursing staff, including RNs and the Infection Preventionist, confirmed that the facility's protocol required monitoring for side effects such as rash, hives, dizziness, allergic reactions, nausea, vomiting, and changes in cognition during antibiotic therapy. Staff stated that this monitoring should be documented in the Medication Administration Record (MAR) or progress notes. However, record reviews and staff interviews revealed that there was no documentation of such monitoring for the affected residents during their antibiotic courses. The Director of Nursing verified that there was no documentation of antibiotic monitoring in the MAR or progress notes for the residents in question. The facility's policy on antibiotic prescribing practices required protocols for monitoring and documentation as part of its Antibiotic Stewardship Program, but random audits found these requirements were not met for the residents identified.