Missed IV Antibiotic Doses Due to Failure in Order Entry and Communication
Penalty
Summary
A deficiency occurred when a resident admitted with multiple stage IV pressure ulcers, osteomyelitis, and paraplegia did not receive prescribed intravenous antibiotics (Piperacillin Sodium Tazobactam and Vancomycin) as ordered for the treatment of osteomyelitis. The hospital discharge instructions included specific orders for both antibiotics, but review of the Medication Administration Record (MAR) showed that the first doses were not administered until two days after admission, resulting in four missed doses of each antibiotic. There was no documentation in the resident's progress notes explaining the missed doses during this period. Interviews revealed that the Unit Manager, who was responsible for reviewing admission orders, did not ensure the antibiotic orders were entered into the electronic medical record upon admission. The admitting nurse did not send the antibiotic orders to the pharmacy or enter them on the day of admission. The pharmacy did not receive the orders until the following day, delaying delivery and administration. The Director of Nursing confirmed that the orders should have been entered and the antibiotics administered sooner.