Failure to Administer Prescribed Antibiotic Doses as Ordered
Penalty
Summary
A deficiency occurred when staff failed to administer four doses of a prescribed antibiotic, Amoxicillin-Potassium Clavulanate 875 mg, as ordered by the physician for a resident with a bacterial infection of a pressure wound. The resident, who was cognitively impaired and dependent on staff for all activities of daily living, had a care plan in place to prevent infection and required medications to be administered as ordered. The physician had performed a debridement on the resident's right hip pressure wound and ordered the antibiotic to be given every 12 hours. The Medication Administration Record (MAR) indicated that all scheduled doses were documented as administered, but a review of the medication package revealed discrepancies between the number of tablets remaining and the number of doses signed off as given. Interviews with staff and review of the medication supply confirmed that the number of antibiotics on hand did not reconcile with the MAR documentation. The facility was unable to identify any other source from which the medication could have been obtained, and there were no other residents receiving the same antibiotic at the time. The expectation was that the number of tablets administered should match the number removed from the resident's supply, but this was not the case, indicating that four doses were not administered as ordered.