Failure to Administer Physician-Ordered Antibiotic Following Hospital Discharge
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, heart failure, dysphagia, and a gastric ulcer, was admitted to the facility and later experienced a choking episode that required hospital transfer. Upon discharge from the hospital, the resident was prescribed Augmentin oral suspension to be administered every 12 hours for nine days to treat aspiration pneumonia. However, upon the resident's return to the facility, the receiving nurse did not include the hospital discharge orders for the Augmentin antibiotic in the resident's medication orders. As a result, the resident did not receive any oral antibiotic from the time of readmission until four days later, when a new order for a different antibiotic, Amoxicillin, was entered and started. The Medication Administration Record confirmed that no oral antibiotics were administered during this period, resulting in eight missed doses. The Director of Nursing verified that the omission occurred due to the failure to transcribe the hospital discharge order for the Augmentin antibiotic upon the resident's return.