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F0658
D

RN Administers Antibiotic Without Physician Order

West, Texas Survey Completed on 09-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A registered nurse (RN) administered an antibiotic injection to a resident without obtaining a physician's order, which is outside the RN's scope of practice and contrary to facility policy. The resident, who had a history of anxiety, unspecified psychosis, urinary tract infection (UTI), and nausea, was admitted with moderate cognitive impairment and required moderate assistance with activities of daily living. Lab results indicated a possible UTI, and further testing was pending to determine the appropriate antibiotic. Despite this, the RN ordered and administered Ceftriaxone from the emergency kit, documenting the action as a preventive measure against sepsis or worsening condition, but without physician authorization. The incident was discovered when the Director of Nursing (DON) reviewed the order and confirmed with the medical director that no order had been given for the antibiotic. The RN admitted to not contacting the physician and stated she assumed the medication would be appropriate based on the resident's history and symptoms. The facility's pharmacy policy requires that no medication be administered without a written physician's order. The medical director confirmed he was not contacted and did not authorize the medication. The resident did not experience any negative outcomes as a result of the unauthorized administration.

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