Failure to Administer Antibiotics as Ordered
Penalty
Summary
Surveyors identified that the facility failed to provide routine and emergency pharmaceutical services to meet the needs of several residents, specifically in the administration of antibiotics. For three residents reviewed, there were multiple instances where antibiotic medications were either not administered at all or were given outside of the prescribed timeframes. Documentation showed that one resident missed two doses and received 21 doses late, another missed four doses entirely, and a third missed one dose and received several doses late for two different antibiotics. These failures were confirmed through review of medication administration records, physician orders, and care plans. The residents involved had significant medical conditions requiring timely antibiotic therapy, including infections such as Methicillin Susceptible Staphylococcus Aureus (MSSA), infective endocarditis, osteomyelitis, and pneumonia. The care plans for these residents included interventions to administer antibiotics as ordered by the physician, yet the medication administration records revealed consistent lapses in following these orders. In some cases, the antibiotics were not available or not administered as scheduled, and in others, there was confusion or miscommunication regarding the reconciliation of hospital discharge orders and the facility's medication administration process. Interviews with nursing staff, the DON, and other facility leadership revealed that there were established protocols for medication reconciliation, order entry, and administration, including the use of pharmacy automation systems like Pyxis. However, staff interviews indicated issues with communication between hospital discharge paperwork, the facility's EMR, and pharmacy processes. There were also inconsistencies in documentation and notification procedures when medications were missed or administered late, with leadership not being informed of these occurrences as required by facility policy.