Failure to Administer Prescribed IV Antibiotics After Hospital Readmission
Penalty
Summary
A significant medication error occurred when a resident returned to the facility from the hospital and did not receive prescribed IV antibiotics, including Vancomycin and Meropenem, as ordered by the hospital physician. The resident, who had multiple complex medical conditions such as respiratory failure, sepsis, pneumonia, and a tracheostomy, was supposed to continue IV antibiotic therapy upon readmission. However, due to a lack of communication and incomplete transfer of clinical records, the antibiotics were not administered for several scheduled doses. The admitting nurse did not receive a report from the hospital at the time of the resident's return and did not take further steps to obtain the necessary information, such as contacting the hospital, the ADON, or the Administrator. As a result, the resident's medication administration record (MAR) did not include the required antibiotics, and the medications were not initiated until the following evening, resulting in four missed doses. The ADON and other staff members later confirmed that the omission was due to missed communication and oversight in reviewing updated clinical records sent by the hospital. Interviews with facility staff revealed that the absence of a Clinical Marketer and the lack of a clear process for handling admissions without a hospital report contributed to the breakdown in communication. The Business Office Manager had attempted to facilitate the transfer of information, but the updated medication list was not reviewed in a timely manner. The resident's physician was eventually notified of the missed doses and adjusted the treatment plan accordingly.