Antibiotic Order Not Followed Due to Medication Entry Error
Penalty
Summary
The facility failed to ensure that an antibiotic was administered as ordered for one resident. The resident, who had multiple diagnoses including pneumonia, major depressive disorder, osteoporosis, severe protein calorie malnutrition, hypothyroidism, chronic obstructive pulmonary disease, and other conditions, was discharged from the hospital with instructions to receive doxycycline 100 mg daily for three days. However, the electronic Medication Administration Record (eMAR) showed that the order was incorrectly entered as a one-time dose rather than a daily dose for three days. As a result, the resident received only one dose of doxycycline instead of the full prescribed course. The Director of Nursing confirmed that the order was entered incorrectly and that only a single dose was administered, contrary to the hospital discharge instructions and facility policy for safe medication administration.