Failure to Administer Ordered Antibiotic and Document Medication Omission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering an ordered antibiotic as prescribed. The resident, an elderly female with multiple diagnoses including dementia, diabetes, anxiety, chronic heart failure, COPD, and chronic pain, was admitted with significant health concerns and was at risk for pressure ulcers. A physician's order was written for Cephalexin 500 mg to be administered every 12 hours for a urinary tract infection, with a specified start and stop date. However, review of the Medication Administration Record (MAR) showed that the antibiotic was not given as ordered on the initial date, and there was no documentation in the progress notes explaining why the medication was not administered or why the start of the antibiotic was delayed. Interviews with facility staff, including the hospice nurse, LVN, and DON, revealed a lack of awareness and clarity regarding the missed dose. The hospice nurse was not informed that the antibiotic was unavailable or not delivered, and stated that if she had been notified, she would have arranged for the medication to be provided. The LVN could not recall the specific incident but suggested that pharmacy issues or delays in entering the order into the computer system may have contributed to the missed dose. The DON confirmed that the expectation was for nurses to obtain the initial dose from the emergency kit and to document any issues, but could not find documentation or recall why the antibiotic was not given as ordered. The resident's family reported noticing a foul urine odor and confirmed that hospice had ordered the antibiotic, expecting it to be started promptly. When the family inquired about the medication, they were told by the LVN that the antibiotic had not been administered due to it not being entered into the system. The facility's medication error logs did not reflect this incident, and the facility's policy required immediate documentation of medication orders and administration, which was not followed in this case.