Failure to Administer Ordered Antibiotic Upon Readmission
Penalty
Summary
A deficiency occurred when a resident was not administered an antibiotic, fluconazole, as ordered by the physician following readmission from a general acute care hospital. The resident, who had significant cognitive impairment and required total assistance with activities of daily living, was readmitted with diagnoses including attention to a gastrostomy and chronic obstructive pulmonary disease. The hospital discharge summary and subsequent physician order specified that fluconazole 200 mg should be given once daily for seven days, starting on the day of readmission. Upon review, it was found that the resident did not receive the first dose of fluconazole on the day of readmission. Nursing staff assumed the initial dose had been administered at the hospital, but there was no confirmation or communication from the hospital to verify this. The medication was available in the facility’s emergency kit, and both nursing staff and the DON acknowledged that the order should have been clarified and the medication administered within four hours of receipt, as per facility policy and standard practice. The failure to administer the antibiotic as ordered was attributed to miscommunication and lack of order clarification regarding whether the first dose had been given prior to transfer. The facility’s policies on medication reconciliation and physician orders emphasized the importance of timely administration and verification of medication history upon admission or readmission, but these procedures were not followed in this instance.