Missed IV Antibiotic Doses Due to Medication Administration Failures
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infection (UTI), type 1 diabetes, right artificial hip with surgical aftercare, urinary retention, and neuromuscular bladder dysfunction was re-admitted to the facility with an order for intravenous (IV) meropenem to be administered every eight hours. Upon return, the resident initially lacked IV access and the medication, requiring EMS intervention and a subsequent hospital visit to re-establish IV access and continue the antibiotic therapy. The resident later had a midline placed for IV administration. On a subsequent occasion, the resident removed their own midline, resulting in a lack of IV access and a missed dose of meropenem. Although the medical provider was notified and an order was given to send the resident to the hospital for a new line, there was a delay in re-establishing IV access, and EMS was eventually contacted to start a new line and administer the antibiotic. There was no evidence that IV access was attempted at the facility before EMS intervention. Additionally, two further doses of meropenem were not administered as scheduled by an LPN, who also failed to notify the Director of Nursing (DON) or a Registered Nurse (RN) about the missed doses, as required by facility protocol. These omissions were documented in employee warning reports and confirmed by the DON, resulting in a total of three missed antibiotic doses for the resident.