Failure to Provide Ordered IV Antibiotic Upon Readmission
Penalty
Summary
The facility failed to provide necessary treatment for a resident who was readmitted with an order for intravenous (IV) Zosyn, an antibiotic required for an abdominal infection following acute appendicitis with abscess. The hospital had communicated the need for IV Zosyn prior to the resident's transfer, and the facility staff, including the RN Case Manager and Director of Nursing, were aware of the requirement. However, upon the resident's arrival, the facility did not have IV Zosyn available, and the in-house pharmacy was closed. Attempts to obtain the medication from the contracted after-hours IV pharmacy were unsuccessful, as the pharmacy was not open during the weekend hours. The facility's process for reviewing new admissions or readmissions included determining whether the facility could meet the resident's care needs. Despite this, the staff did not verify the availability of IV Zosyn before accepting the resident for readmission. The emergency medication kit did not contain IV Zosyn, and the pharmacy manager was not informed in advance about the need for this medication. The facility's after-hours pharmacy contract indicated that emergency or expedited orders could be delivered on weekends and holidays upon mutual agreement, but this process was not successfully executed in this case. As a result of the facility's inability to provide the ordered IV antibiotic, the resident experienced a delay in receiving necessary medication and was subsequently transferred to another facility that could provide the required treatment. The failure to ensure medication availability prior to readmission directly led to the deficiency identified in the report.