Failure to Notify Provider of Missed Antibiotic Doses
Penalty
Summary
The facility failed to notify a provider when an antibiotic prescribed to treat a urinary tract infection was omitted five times for a resident with Alzheimer's disease and type 2 diabetes mellitus. The resident, who had memory recall deficits and was dependent on staff for personal hygiene and toileting, was prescribed cefuroxime axetil to be administered twice daily for ten days. The medication was not administered on five occasions due to reasons such as unavailability, resident refusal, and the resident being on a leave of absence. Documentation in the Medication Administration Record and nurse's notes indicated missed doses, but there was no evidence that the provider or nursing supervisor was notified of these omissions as required by facility policy. Interviews with nursing staff revealed a lack of awareness regarding the requirement to notify the provider for each missed medication dose. The Advanced Practice Registered Nurse confirmed she was not informed of the missed doses and stated that notification could have led to changes in the treatment plan. The Director of Nursing also acknowledged that each missed dose should have been documented with the reason and notification details, and that staff should have reapproached the resident after refusals and documented these actions. The facility's medication administration policy required documentation of refusals, provider notification, and actions taken when medications were unavailable, but these procedures were not followed in this case.