Missed Doses of IV Antibiotic Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that Vancomycin, an IV antibiotic, was administered as ordered for a resident diagnosed with gram-positive bacteremia. The resident was admitted with a history of receiving IV antibiotics in the hospital, and the discharge orders specified daily Vancomycin administration. Upon admission, the facility received an order to start Vancomycin on a specific date and time, but the medication was not available in the facility for two consecutive days. Documentation showed that the pharmacy was contacted and the order was refaxed, with the pharmacy indicating the medication would be delivered that night, but the first dose was not administered until two days after the scheduled start date. The electronic Medication Administration Record (eMAR) and progress notes confirmed that Vancomycin was not administered on the first two scheduled days, and the first dose was given on the third day. The nurse practitioner responsible for the resident was not informed of the missed doses and stated that he would have taken additional steps if he had been notified. The facility's policy required medications to be administered in a safe and timely manner, within one hour of the prescribed time unless otherwise specified, but this was not followed in this instance.