Failure to Administer and Document IV Antibiotic Doses
Penalty
Summary
The facility failed to ensure that a resident received all physician-ordered doses of an intravenous (IV) antibiotic. The resident, who was admitted with multiple diagnoses including acute pyelonephritis, sepsis, bacteremia, urinary tract infection, and acute kidney injury, was prescribed Cefepime-Dextrose IV Solution to be administered every 12 hours for 10 days. Record review showed that on two occasions, there was no documented evidence that the IV antibiotic was administered, refused, or unavailable, and there was no documentation of physician notification or attempts to contact the pharmacy regarding missing medication. Interviews with nursing staff confirmed that medications should be documented as administered or refused on the Medication Administration Record (MAR), and that any unavailability should be reported and documented. However, for the missed doses, there was no documentation in the MAR, progress notes, or any indication that the physician or pharmacy was notified. The facility's policy requires documentation of administration, refusal, or unavailability, but this was not followed in the resident's case.