Antibiotic Administration Omission for UTI
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cellulitis, leg pain, anxiety disorder, and glaucoma did not receive an ordered antibiotic medication as prescribed for a urinary tract infection (UTI). The resident, who had intact cognition and required assistance with mobility and dressing, was ordered to receive Fosfomycin tromethamine 3 gm oral packets every Tuesday, Friday, and Sunday for three doses. The medication was to begin following a positive urine culture and specific antibiotic recommendations. However, the medication was not available on the scheduled administration dates, and the resident did not receive the antibiotic as ordered. Medical record review and staff interviews confirmed that the antibiotic was not administered on the intended dates, with documentation in the medication administration record indicating the medication was unavailable. The issue was identified after two missed doses, and the antibiotic was not given until several days after the initial order. Both the Assistant Director of Nursing and the Director of Nursing verified that the medication was not administered as scheduled, resulting in a significant medication error for the resident.