Missed IV Antibiotic Orders Due to Incomplete Discharge Summary Review
Penalty
Summary
A deficiency occurred when facility staff failed to thoroughly review a hospital discharge summary and clarify physician orders for a newly admitted resident with diagnoses of osteomyelitis and discitis. The discharge summary, spanning 14 pages, included a recommendation for Penicillin G IV every 4 hours for 6 weeks, but this order was not listed on the new medications list. Staff transcribed and administered only the Heparin and Sodium Chloride flushes for the resident's PICC line, omitting the antibiotic order. Nurse #6, responsible for the admission, reviewed the new medications list and discussed it with the on-call Physician Assistant, but did not identify or clarify the missing antibiotic order. Nurse #5, who performed a second check, also failed to locate the antibiotic order and, based on the absence of an explicit order and an instruction to remove the PICC line after the last antibiotic dose, removed the PICC line. This action was taken without confirming with the physician whether the antibiotic course was complete, despite the discharge summary containing instructions to call with any questions regarding antibiotics. The omission resulted in the resident missing six doses of Penicillin G and necessitated a return to the hospital for PICC line replacement. Interviews with staff and the DON confirmed that the antibiotic order was present in the discharge summary but not clearly listed, leading to confusion and lack of clarification. The resident, who was severely cognitively impaired, did not experience further complications from the missed doses, but the error was attributed to incomplete review and failure to clarify ambiguous or missing orders.