Failure to Administer Ordered Antibiotic and Reconcile Controlled Medications in eKITs
Penalty
Summary
The facility failed to ensure that an antibiotic medication, sulfamethoxazole-trimethoprim, was administered as ordered by the physician for a resident with a history of atherosclerotic heart disease, generalized muscle weakness, and a urinary tract infection. The resident, who was cognitively impaired and required maximum assistance for daily activities, did not receive the scheduled 9 a.m. dose on 7/13/2025. Documentation in the Medication Administration Record (MAR) and progress notes did not confirm administration of the medication, and staff interviews confirmed that the dose was missed and not documented. The nurse responsible did not notify the physician about the missed dose or obtain further orders, resulting in an incomplete antibiotic course for the resident's abscess. Additionally, the facility failed to reconcile controlled medications (CMs) stored in emergency medication kits (eKITs) at every shift change in three medication rooms. Observations revealed that six eKITs containing CMs lacked accountability logs for July 2025, and staff interviews confirmed that these kits were not reconciled as required by facility policy. Nurses acknowledged the importance of reconciling CMs at each shift to ensure accountability and prevent diversion, but admitted that this was not done for the identified eKITs. Review of facility policies confirmed that all CMs, including those in emergency kits, must be physically inventoried and documented by two licensed nurses at each shift change. The Director of Nursing and Assistant Director of Nursing acknowledged that the facility did not follow its own procedures for CM reconciliation, and that the required documentation and accountability for these medications were not maintained during the period in question.