Antibiotic Administered Beyond Prescribed Duration Due to Order Entry Error
Penalty
Summary
A resident with severe cognitive impairment was prescribed doxycycline 100 mg twice daily for seven days to treat a pneumonia identified by chest x-ray. The physician's order, dated 5/12/25, specified the duration of therapy as seven days. However, the medication was administered from the evening of 5/12/25 through the evening of 5/27/25, exceeding the prescribed duration. Review of the pharmacy delivery log confirmed that 14 tablets were initially delivered, but additional doses were obtained from the Emergency Drug Kit on multiple occasions after the original supply was exhausted. The Director of Nursing confirmed that the antibiotic was not discontinued as ordered because the stop date was included only in the text of the order and not entered correctly into the system, resulting in continued administration beyond the intended stop date. Facility policy required prescribers to provide complete antibiotic orders, including start and stop dates or number of days of therapy.