Failure to Clarify and Administer Admitting IV Antibiotic Order
Penalty
Summary
The facility failed to ensure that an admitting order for an intravenous antibiotic (Oxacillin) for a resident with diagnoses including septic arterial embolism, bacteremia, and methicillin-susceptible Staphylococcus aureus infection was clarified by the resident's primary care physician upon admission. The facility's Medication Reconciliation policy required that all discrepancies in medication orders, including dosage, frequency, and stop date, be reviewed and clarified with the physician and documented in the resident's medical record. Upon admission, the discharge reconciliation document from the hospital had a question mark next to the Oxacillin order, indicating the need for clarification. However, the Unit Manager did not obtain the necessary clarification, resulting in the medication not being ordered or administered as prescribed. As a result of this failure, the resident missed five doses of the prescribed IV antibiotic. The issue was identified when the DON reviewed new admissions and noted the missing medication on the resident's MAR. Staff interviews confirmed that the nurse responsible for the admission relied on the Unit Manager to complete the paperwork and obtain clarification, but the clarification was not obtained, and the medication was not administered until the error was discovered. The deficiency was directly related to the lack of timely clarification and transcription of the antibiotic order during the admission process.