Failure to Administer IV Antibiotics and Notify Physician of Missed Doses
Penalty
Summary
A deficiency occurred when a resident admitted with end stage renal disease, Parkinson's Disease, type 2 diabetes, and osteomyelitis did not receive ordered intravenous (IV) antibiotic therapy as prescribed. The resident was admitted for the primary purpose of receiving IV Cefazolin to treat a bone infection. Despite physician orders for daily administration of Cefazolin, the resident did not receive four consecutive doses following admission, with the first dose not administered until several days later. The facility's policy required nursing staff to contact the pharmacy, attempt to obtain the medication from available sources, and notify the physician if a medication was unavailable. Documentation in the resident's medical record indicated that the antibiotic was not on hand and that there were difficulties establishing IV access, including unsuccessful attempts to start a line and delays in obtaining a midline due to the need for renal clearance. However, there was no documentation that the resident's physician was notified of the missed doses or the unavailability of the medication during this period, nor was there evidence of alternative orders or instructions from the physician regarding the missed therapy. Interviews with facility leadership confirmed that the expectation was for the physician to be informed of missed medication doses and for this communication to be documented in the resident's record. The record review and staff interviews revealed that the physician was not made aware of the missed doses until several days after the initial missed administrations, and the medical record did not reflect timely notification or a plan to address the missed antibiotic therapy.