Failure to Administer Prescribed Antibiotic as Ordered
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not administering Levofloxacin as ordered by the provider. The provider's order specified that the resident was to receive Levofloxacin 750 mg orally once daily for five days, starting on 3/11/25. However, review of the medication administration record (MAR) and clinical documentation showed that the resident only received four doses of the medication, rather than the prescribed five. On the first scheduled day, the resident was marked as being on a leave of absence due to a hospital transfer and did not receive the medication. The resident involved had multiple complex diagnoses, including Progressive Multifocal Leukoencephalopathy, Chronic Kidney Disease, Acute Kidney Failure, and Acute Respiratory Failure with Hypoxia, among others. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. Despite the facility's policy requiring medications to be administered as ordered, the missed dose was not addressed, resulting in the resident not receiving the full prescribed course of antibiotic therapy.