Failure to Administer Ordered IV Antibiotics Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering physician-ordered intravenous (IV) antibiotics as prescribed. The resident, who had a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and other conditions, 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 initial 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 and lack of clarity among nursing staff regarding medication availability, administration times, and communication with pharmacy and providers. Multiple staff interviews indicated that medication orders were not promptly entered or administered due to issues such as medication and pump availability, lack of stat delivery requests, and unclear communication with pharmacy and providers. Nurses reported uncertainty about the process for obtaining urgently needed medications and did not consistently document missed doses or provider notifications. The pharmacy confirmed that stat deliveries and replacement IV pumps were available upon request, but staff did not utilize these options effectively. Facility policy required immediate action and provider notification when medications were unavailable, but these procedures were not followed. As a result of the missed antibiotic doses, the resident experienced a change in condition, including altered mental status, and was subsequently transferred to the hospital, where he was diagnosed with sepsis. Hospital records and provider notes indicated that the lack of proper antibiotic administration contributed to the resident's acute condition. The facility's failure to administer essential antibiotics as ordered, document actions taken, and communicate effectively with pharmacy and providers led to significant harm and was identified as an Immediate Jeopardy situation.