Failure to Provide Timely IV Antibiotic Therapy for New Admission
Penalty
Summary
The facility failed to ensure that intravenous (IV) antibiotic medication was available and administered as ordered for a newly admitted resident with a diagnosis of osteomyelitis of the left ankle and foot. The resident was admitted with a physician's order for cefazolin 2 grams IV every 8 hours for 42 days. Upon admission, the resident had IV access in place, but the ordered antibiotic was not available for several scheduled doses. Documentation in the Medication Administration Record (MAR) indicated missed doses, with notes from nursing staff stating the medication was on order or awaiting delivery from the pharmacy. Multiple nursing staff interviews confirmed that the medication was not available at the facility at the time of admission and for subsequent scheduled doses. Nurses reported contacting the pharmacy, which indicated that the medication would be delivered on the next run, but it was not included in the initial deliveries. The emergency dose kit at the facility did not contain IV cefazolin, and staff were unaware of its availability in the kit. The resident expressed concern about missing several doses of the antibiotic and reported notifying nursing staff about the missed medication. Interviews with the pharmacist revealed that the pharmacy had a cut-off time for sending IV antibiotics for new admissions, and delays could occur if residents were admitted after this time or due to pharmacy staffing or documentation issues. The Medical Director and Director of Nursing acknowledged the lack of an effective system to ensure timely availability of medications for new admissions, particularly for IV antibiotics. The administrator was not aware of any issues with timely delivery of IV medications for new admissions.