Failure to Administer Prescribed IV Antibiotics and Ensure Staff Competency
Penalty
Summary
The facility failed to protect a resident from medical neglect by not ensuring the administration of prescribed intravenous (IV) antibiotics according to physician orders. The resident, who had a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and a recent surgical intervention, was admitted with orders for Vancomycin 1500 mg IV every 8 hours and Cefepime 1 g IV every 8 hours. Despite these orders, the resident received an incorrect dose of Vancomycin (1000 mg instead of 1500 mg) and subsequently missed eight consecutive doses of Vancomycin over several days. There were also missed doses of Cefepime. Documentation and interviews revealed confusion among nursing staff regarding medication availability, order entry, and the process for obtaining stat deliveries or alternative medications from the pharmacy. Nursing staff failed to follow facility policies and procedures for medication administration, physician notification, and documentation. Several nurses reported uncertainty about whether medications could be administered without a pump, whether stat deliveries could be requested, and whether alternative sources for medications or equipment were available. There was a lack of timely communication with providers regarding missed doses, and documentation of provider notifications and orders was inconsistent or absent. The pharmacy confirmed that stat deliveries and replacement IV pumps were available upon request, but staff did not utilize these options appropriately. Additionally, there were concerns about staff competency, including whether nurses had the appropriate IV certification to administer the medications safely. The resident began to exhibit a change in condition, including altered mental status, which was first identified by a family member. Despite the family member's concerns and requests for hospital transfer, facility staff did not recognize or respond to the change in condition in a timely manner. When the resident was eventually transferred to the hospital, he was diagnosed with sepsis and found to have subtherapeutic Vancomycin levels, as well as evidence of ongoing infection and abscess formation. Interviews with facility leadership and providers confirmed that the expected processes for medication administration, provider notification, and documentation were not followed, resulting in significant medication errors and harm to the resident.