Missed IV Antibiotic Doses Due to Medication Unavailability on Admission
Penalty
Summary
A deficiency occurred when a resident admitted with osteomyelitis of the left ankle and foot did not receive four scheduled doses of intravenous cefazolin antibiotic as ordered by the physician. The medication was to be administered every eight hours, but was not given at four scheduled times due to the medication not being available in the facility. Nursing staff documented the missed doses, citing reasons such as the medication being on order, not yet delivered from the pharmacy, or awaiting arrival. Multiple nurses confirmed in interviews that the cefazolin was not available for administration and that they either contacted the pharmacy or expected the medication to arrive later. The backup medication dispensing system did not contain cefazolin, and not all staff contacted the pharmacy to check on the delivery status. The resident, who was cognitively intact and had intravenous access, reported missing several doses of the antibiotic upon admission. The physician was notified of the missed doses and adjusted the medication schedule to ensure the total prescribed doses would be administered. The DON explained that new admission orders could not be activated until the resident arrived, which sometimes led to delays in medication delivery, especially for late evening admissions. The administrator confirmed that the DON was responsible for ensuring the availability of IV antibiotics as ordered.