Medication Administration Errors Result in Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, resulting in significant medication errors for two residents. For one resident with osteomyelitis and sepsis, the hospital discharge order specified Vancomycin treatment for six weeks, ending on 10/13/2025. However, the medication was discontinued early on 10/03/2025 due to an error in the stop date entered by staff, which was based on a miscommunication and a typographical mistake in the order. The pharmacy confirmed the original order was through 10/13/2025, but the facility's records reflected the incorrect earlier stop date, leading to premature discontinuation of the antibiotic. Another resident with diabetes, hypertension, and an amputation had two overlapping orders for Doxycycline. The first order was for a seven-day course, and the second was to continue the medication indefinitely. The Medication Administration Record (MAR) showed that the evening dose on 11/05/2025 was not administered, as indicated by a blank entry and a red mark in the MAR, which staff confirmed meant the medication was not given. Staff interviews acknowledged the error and the importance of administering the full course of antibiotics as ordered.