Failure to Administer Prescribed IV Antibiotic Due to Medication Unavailability and Staff Oversight
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by missed doses of Meropenem IV solution prescribed for an infected sacral wound. The resident, who had diagnoses including hyperosmolality, hypernatremia, major depressive disorder, and a pressure ulcer, was admitted with moderate cognitive impairment. Physician orders specified Meropenem IV every eight hours for 14 days, but the medication administration record showed multiple missed doses over several days. Pharmacy records and progress notes confirmed that the medication was not administered because it was reported as being on order, and there were delays in receiving the medication supply. Interviews with facility staff and the pharmacy representative revealed that the initial supply of Meropenem was delivered, but subsequent doses were missed due to a lack of medication availability and a failure by an agency nurse to locate the IV medications. The Director of Nursing verified the missed doses and attributed the issue to the agency nurse not asking about the storage location of IV medications. Facility policy required medications to be administered in a safe and timely manner, within one hour of the prescribed time, but this was not followed in this instance.