Failure to Provide IV Antibiotics Due to Pharmacy Service Disruption
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of intravenous (IV) antibiotics. One resident, who had been readmitted with a diagnosis of pelvic osteomyelitis, had physician orders for Meropenem IV every 8 hours. The medication was not administered on four occasions over a two-day period due to the facility's inability to obtain the IV antibiotic from the pharmacy. Nursing documentation confirmed the missed doses, and the resident reported experiencing symptoms such as chills and feeling feverish after missing the antibiotics. Staff interviews revealed that the pharmacy previously contracted to provide IV medications had ended their service, and nursing staff were unclear about how to obtain IV medications under the new arrangement. Another resident was admitted with a right hip peri-prosthetic joint infection and had physician orders for Daptomycin and Ertapenem IV antibiotics. The resident did not receive the ordered IV antibiotics because the pharmacy was unable to deliver them, resulting in the resident being transferred back to the hospital the day after admission. Staff interviews confirmed that the facility was unable to secure IV antibiotics for this resident due to the change in pharmacy services, leading to missed doses and the need for hospital transfer.