Missed Antibiotic Doses Due to Medication Unavailability and Documentation Lapses
Penalty
Summary
The facility failed to administer the ordered initial dose of an antibiotic to a resident being treated for a urinary tract infection (UTI). The nurse practitioner's progress note documented a plan to treat the resident with Levofloxacin IV, starting with a 750 mg dose, followed by a 500 mg dose every 48 hours, and Meropenem 500 mg IV daily. The Medication Administration Record (MAR) showed a missed dose of Meropenem on 9/14/25 and no documentation of the administration of the initial Levofloxacin 750 mg dose on 9/13/25 or 9/14/25. Nursing notes indicated that Levofloxacin was not available and would be delivered later, but there was no documentation that the dose was ever administered. The Director of Nursing confirmed there was no documentation of the administration of either the Meropenem dose or the initial Levofloxacin dose, and no authorization requests were received from the pharmacy for the one-time Levofloxacin dose. Facility policy requires prompt reporting of medication discrepancies and omissions, but this was not documented in this case.