Delayed Antibiotic Administration Due to Medication Access and Communication Failures
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident who had recently undergone a right below-the-knee amputation and was at risk for infection. The resident was prescribed Cleocin (Clindamycin) 150mg, two capsules three times daily, by a vascular surgery nurse practitioner to treat a surgical wound infection. Despite the order being placed, the antibiotic was not started as directed. Documentation shows that the medication was available in the facility's Pyxis medication dispensing system, but the nurses on duty did not have access to the Pyxis and therefore could not obtain the medication for administration. The medication was delivered from the pharmacy and was present in the facility, but it was not placed in the correct location for the nurses to find and administer. As a result, the resident missed multiple scheduled doses of the antibiotic over two days. Progress notes and interviews confirm that staff were waiting for the medication to be delivered, unaware that it was already available in the Pyxis or had been delivered and misplaced. The lack of access to the Pyxis and failure to check for the medication's availability led to a delay in starting the antibiotic treatment. Due to the delay in receiving the prescribed antibiotic, the resident's infection worsened, resulting in hospitalization for a non-healing surgical wound and infection. The hospital nurse reported that the resident required intravenous antibiotics and was scheduled for further surgical intervention. The facility's own policy required medications to be administered in a safe and timely manner as prescribed, but this was not followed in this case, leading to actual harm for the resident.