Missed Vancomycin Doses and Lack of Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including bacterial arthritis, MRSA, diabetes, chronic kidney disease, and congestive heart failure, did not receive several scheduled doses of Vancomycin as ordered by their physician. The resident, who had a PICC line for intravenous antibiotics, reported that three doses of Vancomycin were missed. Review of the Medication Administration Record (MAR) showed that on four occasions, Vancomycin doses were either marked with codes indicating 'see Nurse Note' or 'HOLD see Nurse Note,' or lacked any documentation of administration or reason for omission. No corresponding nurse progress notes were found to explain why the medication was not given or held on these dates. Interviews with nursing staff and the Director of Nursing revealed that the expected protocol was to notify the physician of any missed medication doses and document the reason in a progress note. The LPN interviewed stated that a code indicating a missed dose should be accompanied by a detailed progress note, and that missing documentation in the MAR should be flagged for review by nursing leadership. Despite these expectations, there was no documentation to account for the missed Vancomycin doses, resulting in the resident not being free from significant medication errors.