Antibiotic Administered Without Laboratory Confirmation
Penalty
Summary
A resident was prescribed and administered an antibiotic, Cefuroxime Axetil, for a presumed urinary tract infection (UTI) without laboratory confirmation of the infection. The resident exhibited decreased energy and was not acting like herself, prompting the facility to order a urine analysis (UA). However, due to repeated issues with the laboratory not picking up the urine specimen, no urinalysis results were obtained. Despite the absence of diagnostic confirmation, the resident was started on the antibiotic and received eight doses over several days. Progress notes and interviews confirm that both the nurse practitioner and the director of nursing were aware that the urine specimen had not been collected or processed, yet the antibiotic regimen was initiated and continued. The facility's policy requires that medications be administered only with adequate clinical indications, which was not met in this case as there was no documented evidence of a UTI or laboratory results to support the use of antibiotics.