Failure to Administer IV Antibiotics as Prescribed and Monitor for Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during their stay. The resident, who had a complex medical history including sepsis, chronic kidney disease, diabetes, and morbid obesity, was admitted from a hospital with orders for intravenous (IV) antibiotic therapy (ertapenem sodium) to be administered daily. Despite these orders, the resident missed two doses of the antibiotic and received ten doses more than an hour past the prescribed time. There was no documentation that these medication errors were reported to the Director of Nursing, the primary care physician, or the responsible party, as required by facility policy. Nursing staff did not document or monitor for side effects during the administration of the IV antibiotic, nor did they conduct or record change of condition assessments following the missed or late doses. The facility's policies required that all medication errors be documented, reported, and reviewed, and that any change in a resident's condition, including missed or late medication doses, be communicated to the appropriate parties and recorded in the resident's medical record. However, interviews with nursing staff and the DON confirmed that these steps were not taken, and no audits or follow-up actions were documented regarding the missed or late doses. The lack of timely administration and monitoring of the IV antibiotic, as well as the failure to follow established protocols for reporting and documenting medication errors and changes in condition, resulted in the resident not receiving antibiotics as prescribed. This had the potential to contribute to the resident's subsequent transfer to a general acute care hospital. The facility's failure to adhere to its own medication administration and change of condition policies was confirmed through interviews, record reviews, and policy examination.