Missed Antibiotic Dose Due to Medication Unavailability and Communication Failure
Penalty
Summary
The facility failed to ensure that antibiotics were administered as ordered by the physician for a resident with a history of acute kidney failure, malignant neoplasm, and anxiety disorder. The resident was prescribed azithromycin for a sinus infection, with instructions to take two tablets on the first day and one tablet daily for the next four days. Documentation showed that the final dose of azithromycin was not administered because the medication was unavailable. The pharmacy initially delivered only five tablets instead of the required six, resulting in a missed dose. The missing tablet arrived the following night, but by then, the resident had already started a new course of antibiotics. Licensed nursing staff did not notify the physician or nurse practitioner about the missed dose, nor did they leave notes for other nurses regarding the unavailability of the medication. The Director of Nursing confirmed that there was no documentation in the secure communication system indicating that the missed dose was reported to the provider. The resident was aware of the missed dose and reported no ongoing issues at the time of the interview. The facility's policy required staff to notify the pharmacy and the physician when medications were unavailable, but this protocol was not followed in this instance.