Missed Dose of Physician-Ordered Antibiotic
Penalty
Summary
A resident with diagnoses including diabetes mellitus and a sacral pressure ulcer was admitted to the facility and placed on enhanced barrier precautions due to a gastrostomy tube and pressure injury. The resident's care plan included the administration of antibiotic medications as ordered by the physician. A physician's telephone order was received to administer metronidazole 500 mg via gastrostomy tube every eight hours for the pressure sore. According to the Medication Administration Record (MAR) and the resident's metronidazole bubble pack, the resident was supposed to receive a total of 10 doses of metronidazole over a specified period. Upon review, it was found that only nine doses of metronidazole were administered, as confirmed by both the MAR and the medication bubble pack. This discrepancy was acknowledged by two LVNs during a concurrent interview and record review. The facility's policy and procedures required medications to be administered in a safe and timely manner as prescribed, but the resident missed one dose of the ordered antibiotic.