Failure to Administer and Document IV Antibiotics as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including osteomyelitis of the thoracic vertebrae, local skin infection, and sepsis did not receive several prescribed intravenous antibiotic doses. Physician orders required administration of cefepime and vancomycin every 12 hours, but the Medication Administration Record (MAR) showed blank entries for multiple scheduled doses, indicating they were either not given or not documented. There was no evidence in the nursing progress notes of missed doses or provider notification regarding these omissions. Interviews with nursing staff revealed confusion and inconsistency regarding responsibility for intravenous medication administration and documentation. LPNs and RNs described different processes for being alerted to medication times, and some staff were unsure why MAR entries were left blank. Supervisory staff acknowledged that a blank MAR box meant the medication was unaccounted for, and that this constituted a medication error. However, there was no documentation of any investigation into the missing administrations, nor was there evidence that the provider was notified as required by facility policy. The physician responsible for the resident's care confirmed that they were not notified of any missed antibiotic doses, which they considered a significant medication error. Facility leadership, including the DON and Assistant DON, stated that all MAR entries should be completed and that missed or undocumented doses should be investigated and reported. Despite this, no such actions were documented, and the missed doses remained unaccounted for.