Failure to Monitor Antibiotic Therapy and Adhere to Medication Orders
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident with end-stage renal disease, diabetes mellitus, and multiple chronic wounds who was prescribed antibiotics for wound infection. The resident's care plan directed staff to administer antibiotics as ordered and to monitor for adverse reactions and continued signs and symptoms of infection, as well as for dehydration. However, review of the clinical record and medication administration documentation revealed that staff did not consistently monitor or document the effectiveness and side effects of the antibiotics. Additionally, the resident continued to receive atorvastatin, a cholesterol-lowering medication, despite physician instructions to hold this medication while the resident was taking ciprofloxacin, an antibiotic with potential for adverse interactions. Interviews with nursing staff confirmed that monitoring for antibiotic effectiveness and adverse reactions was not performed or documented as required. Staff were also unaware of the order to hold atorvastatin during antibiotic therapy, and the medication was administered concurrently with ciprofloxacin. The facility's medication management policy required ongoing monitoring for safe and effective medication use, but this was not followed in the resident's case, as evidenced by the lack of documentation and failure to adhere to physician orders.