Missed IV Antibiotic Dose Due to Failure to Change Cartridge
Penalty
Summary
A resident with multiple diagnoses, including osteomyelitis of the thoracic vertebra, was admitted to the facility and prescribed a continuous 24-hour intravenous (IV) antibiotic (cefazolin) administered via a CADD pump. The resident was cognitively intact and made their own medical decisions. On one occasion, the scheduled change of the antibiotic cartridge was not performed as ordered, resulting in the resident missing a dose of the IV antibiotic. The missed dose was confirmed by both the resident and multiple staff members, who noted that the cartridge was found dry and unchanged the following day, and an unused cartridge was left over and subsequently discarded. The Director of Nursing (DON) was responsible for the shift when the cartridge should have been changed but did not perform the task. The medication administration record indicated the dose was given, but staff interviews and the presence of an unused cartridge confirmed the dose was missed. The incident was reported to the Nursing Home Administrator (NHA), who initially did not investigate further based on the DON's assurance that the dose was not missed. The deficiency was identified through staff and resident interviews, as well as review of medical records and medication supplies.