Failure to Administer and Supply Ordered Antibiotic for C-diff
Penalty
Summary
The facility failed to ensure the timely supply and administration of a prescribed antibiotic medication for a resident with a diagnosis of diabetes mellitus type 2, neuromuscular dysfunction of the bladder, neurogenic bowel, and a terminal diagnosis of CVA. The resident was admitted with septic shock and diarrhea, and had a positive test for clostridium difficile (C-diff), for which vancomycin was ordered. According to the Medication Administration Record, five doses of vancomycin were missed on specific dates, and a Medication Error Incident summary later identified a total of seven missed doses. There was no documentation that the provider or pharmacy was notified about the missed doses or the lack of medication supply. Interviews revealed that the nurse practitioner was unaware of the missed doses and noted ongoing communication challenges with the facility. The DON confirmed that nurses had not notified the physician or pharmacy about the medication shortage, which was expected per facility policy. The pharmacist stated that the pharmacy had not received any request for a refill and that the facility had multiple ways to request additional medication. Facility policy required staff to accurately transcribe medication orders and communicate with the pharmacy as directed, but this was not followed in this case.