Missed Antibiotic Doses Due to Medication Unavailability and Lack of Physician Notification
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including hemiplegia, epilepsy, and pneumonia, did not receive their prescribed antibiotic medication as ordered by the physician. The resident was dependent on staff for several activities of daily living and had intact cognition. The physician ordered Levofloxacin 250 mg, three tablets (totaling 750 mg), to be administered once daily for several days. The medication was administered as ordered on the first two days, but on the following two days, the medication was not available and was not given to the resident. There was no documented evidence that the physician was notified about the missed doses on either day. Staff interviews confirmed that the medication was not available in the facility's medication dispensing system and that the pharmacy was contacted, but the medication was not delivered. Facility policy required medications to be administered only as prescribed, but this was not followed in this instance, resulting in the resident missing two doses of their antibiotic without physician notification.