Failure to Administer Antibiotic and Antianxiety Medications as Ordered
Penalty
Summary
A resident with diagnoses including paraplegia, osteomyelitis, anxiety, hypertension, muscle weakness, and ulcerative colitis was admitted to the facility and had physician orders for both an antibiotic (vancomycin) and an antianxiety medication (alprazolam). The Medication Administration Record (MAR) showed that vancomycin was not signed out as administered for four consecutive doses, and alprazolam was not signed out as given on multiple dates. The resident was cognitively intact and had reported to staff that she was supposed to be on antibiotics. The Assistant Director of Nursing (ADON) indicated that the facility did not receive the After Visit Summary (AVS) from the hospital at admission, which resulted in missing information about the vancomycin order. Despite attempts to obtain the AVS and follow up with the hospital, the facility did not verify the antibiotic order with the physician in a timely manner, leading to missed doses. Additionally, the pharmacy did not fill the alprazolam prescription because they never received a prescription, and nursing staff could not provide an explanation for the missed administration of the antianxiety medication.