Failure to Respond to Pharmacy Drug Interaction Alert Resulting in Missed Antibiotic Doses
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy notification regarding a drug interaction for a resident who was prescribed Cipro for a urinary tract infection (UTI). The resident, who was cognitively intact and admitted with diagnoses including UTI and urinary retention, had a new order for Cipro. The pharmacy identified a potential drug interaction between Cipro and tizanidine and notified the facility, requesting clarification or a change in medication. Despite this notification, the pharmacy did not receive a response from the facility, and as a result, did not send the Cipro to the facility. During this period, documentation showed that the resident received only three out of ten scheduled doses of Cipro, with some doses being documented as administered from prepackaged medications. The Certified Pharmacy Technician confirmed that the medication was withheld pending clarification, and the DON acknowledged that the pharmacy's recommendation was not completed. The nurse practitioner was not made aware of the missed doses until several days later. The breakdown in communication and failure to act on the pharmacy's alert led to the resident not receiving the prescribed antibiotic as ordered.