Failure to Administer Prescribed IV Antibiotics and Anticoagulant
Penalty
Summary
A deficiency occurred when a resident with a history of sepsis, right hip fracture, dementia, and recent surgery was not administered prescribed IV antibiotics and anticoagulant (Lovenox) as ordered. Upon admission and re-admission, the resident required IV antibiotics via a PICC line and daily Lovenox injections. The facility failed to administer several doses of Cefazolin due to issues such as awaiting pharmacy delivery and problems with the PICC line, including it being pulled out or becoming clotted. Documentation showed that the resident missed multiple doses of both antibiotics and Lovenox, with refusals and technical issues cited, but there was inconsistent and delayed communication with the physician and responsible party regarding these missed doses and changes in medication route. Nursing staff interviews revealed confusion and lack of clarity regarding the process for replacing or unclogging the PICC line, as well as uncertainty about the availability of medications in the facility's emergency kit. Staff reported that the resident was difficult to medicate due to behavioral issues, such as swatting at nurses and pulling at the PICC line, but there was no consistent protocol followed for timely physician notification or for obtaining alternative medication routes. The facility's own policies required prompt administration of medications and immediate physician notification if a dose was missed, but these procedures were not consistently followed. Further, administrative and clinical leadership, including the DON and ADON, were not always aware of the missed doses or the status of the PICC line until after the fact. There was no formal tracking system for medication delivery timeliness, and communication between nursing, pharmacy, and providers was not always immediate or documented. The facility had resources such as an emergency kit and contracts for stat medication delivery, but these were not effectively utilized to prevent missed doses of critical medications for the resident.