Failure to Administer Prescribed IV Antibiotic Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including sepsis due to E. coli, severe wounds, and dependence on renal dialysis, was admitted to the facility. Upon admission, the resident had physician orders for IV antibiotic therapy (Piperacillin-Tazobactam/Zosyn) to treat infections related to wounds, urinary tract, and pneumonia. Despite these orders, the resident did not receive the prescribed IV antibiotic from the time of admission for several days. Record reviews showed that the medication was not administered as ordered, and there was no documentation of administration for multiple scheduled doses. Additionally, there was confusion regarding IV access, with delays in arranging for a midline catheter and issues with the pharmacy dispensing the correct antibiotic dosage. Interviews with facility staff revealed that the admitting nurse did not ensure all admission orders were entered before the end of her shift, and there was a lack of timely communication with the medical provider regarding the inability to administer the antibiotic. The medical director and nurse practitioners were not notified of the missed doses or the issues with medication availability and IV access. The wound care physician was also unaware that the resident had not received the ordered antibiotic therapy. Progress notes indicated that the resident had no IV access for the antibiotic, and there was a delay in obtaining the correct medication from the pharmacy. The facility's policy required medications to be administered as prescribed and for staff to notify providers of any issues, but these procedures were not followed. The resident's condition was further complicated by extensive wounds, including stage four pressure ulcers and necrotic tissue, and she was nonverbal and dependent on staff for all care. Observations documented the severity of her wounds and her lack of response to painful procedures, likely due to her cognitive and physical impairments. The failure to administer the prescribed IV antibiotic as ordered was identified as a significant medication error, and the facility was cited for not ensuring residents were free from such errors.
Removal Plan
- SBAR/Change of condition assessment completed with notification of provider and responsible party regarding the missed IV antibiotics.
- Correct dosage of IV antibiotics have been obtained by facility and are being administered as ordered.
- 100% audit completed of facility residents to identify any residents with IV antibiotics. No additional residents identified as receiving IV antibiotics.
- 100% audit completed of facility residents to identify any missed medications and/or treatments. Providers for residents identified as missing medications/treatments were notified and medication error documentation completed on facility residents identified as missing medications/treatments.
- Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding: admission Process to include reconciling treatment and medication orders.
- Medication Administration policy in-serviced for enforcement (no revision of policy required, as policy is effective but not being followed).
- DON/ADON will in-service facility staff by phone and/or in person regarding facility policy on Abuse/Neglect. Facility staff, including PRN staff, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding the admission Process to include reconciling treatment orders and medication orders. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RN) by phone and/or in person regarding Medication Administration. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will monitor admission Process daily to ensure any new admissions and readmissions had reconciled treatment and medication orders.
- Nursing administration designee will complete admission checklist audit to ensure medication reconciliation has been double checked from what was ordered versus what the facility staff enters into the facility's electronic record.
- DON/Designee will monitor Medication & Treatment Administration Records daily to ensure all medications & treatments were signed out, administered, and available by utilizing the Missed Med Report during morning clinical meeting.