Failure to Administer Prescribed Antibiotic Following Hospital Readmission
Penalty
Summary
A significant medication error occurred when a male resident with a history of mild cognitive impairment, generalized muscle weakness, type 2 diabetes, and chronic prostate cancer was readmitted to the facility following a hospital stay for sepsis related to a prostate infection. Upon discharge from the hospital, the resident was prescribed Ciprofloxacin 500 mg orally twice daily for four weeks to treat the prostate infection. The hospital discharge orders, which included this antibiotic regimen, were provided to the facility upon the resident's return. Despite the clear hospital orders, facility staff failed to transcribe and initiate the antibiotic therapy. Review of the resident's medical record, Medication Administration Record (MAR), and order summary revealed no documentation of the Ciprofloxacin order or its administration during the resident's stay from readmission until his subsequent transfer back to the hospital. Multiple nursing progress notes and interviews with staff confirmed that no interventions or treatments, including the prescribed antibiotic, were documented or provided during this period. Staff interviews indicated a lack of clarity and recall regarding the review and implementation of the hospital discharge orders, and the DON did not oversee or in-service staff on the admission/readmission and medication order process during the relevant timeframe. The resident's condition did not improve, and family members requested his transfer back to the hospital, where he was again diagnosed with severe sepsis. Hospital records confirmed that the resident had not received his prescribed antibiotics during his stay at the facility, and this omission was acknowledged by facility staff. The failure to administer the ordered antibiotic was directly linked to the lack of order transcription and follow-through on hospital discharge instructions, as well as insufficient oversight and communication among nursing staff and leadership.