Missed Dose of IV Antibiotic Due to Failure to Follow Physician Order
Penalty
Summary
Facility staff failed to follow physician orders for medication administration for one resident. The resident, who was cognitively intact and had multiple diagnoses including osteomyelitis, MRSA, end stage renal disease, protein-calorie malnutrition, anemia, hypertension, and diabetes, had a physician's order for Zosyn (piperacillin-tazobactam) IV to be administered every 12 hours for treatment of acute osteomyelitis. The medication administration record showed that the scheduled 6:00 a.m. dose on 2/11/25 was not given, and there was no documented reason or physician order to discontinue or stop the medication at that time. A nursing note ambiguously stated "Informed IV completed," but this was not supported by any discontinuation order or further explanation in the clinical record. Interviews with the DON, RN infection preventionist, and regional nurse consultant confirmed that the Zosyn order was not discontinued or completed on the date in question, and they were unable to explain why the dose was missed. The nurse practitioner confirmed awareness of the missed dose and stated that the resident's labs and vital signs remained stable, with no indication to alter the antibiotic regimen. The LPN responsible for the missed dose was unavailable for interview. Facility policy requires medications to be administered according to prescriber orders, which was not followed in this instance.