Delay in Antibiotic Administration Due to Unconfirmed Pharmacy Order
Penalty
Summary
The facility failed to ensure that a physician-ordered antibiotic, cefazolin, was available and administered as scheduled for a resident diagnosed with osteomyelitis of the thoracic vertebra. The resident was admitted with this diagnosis and had a physician's order for intravenous cefazolin to be given every eight hours. However, review of the medication administration record showed that the first dose was not given until two days after the scheduled start date, and several scheduled doses were missed and not documented as administered. Interviews with facility staff and the pharmacist revealed that the delay occurred because the antibiotic order was not confirmed in the electronic record system, which prevented the pharmacy from processing and delivering the medication in a timely manner. The pharmacist stated that the pharmacy only became aware of the order after an urgent call from the facility, and the order was not transmitted until it was confirmed by a nurse. The DON explained that the facility's process requires a nurse to enter and another nurse to confirm the order in the system before the pharmacy can send the medication. The resident did not experience any documented adverse effects from the missed doses.