Failure to Administer Prescribed Antibiotic Due to Medication Order Entry Error
Penalty
Summary
The facility failed to ensure that a resident's prescribed medication, Meropenem, was administered as ordered by the infectious disease provider. The resident, who was admitted with a wound infection and was cognitively intact, had a care plan and provider orders specifying a four-week course of Meropenem 1g IV every 8 hours. However, a review of the resident's physician orders and medication administration records showed that Meropenem was never ordered or administered. Instead, the resident received a different antibiotic, Zosyn, during their stay. Interviews with facility staff revealed that the process for entering admission medication orders involved the medical records department inputting orders into the electronic medical record system (PCC), followed by review and activation by two nurses. The infectious disease clinic's orders for Meropenem were faxed and scanned into the resident's record before admission, but were not entered into the system for review and activation. This communication error resulted in the omission of the Meropenem order, and staff were unaware of the issue until notified by the infectious disease provider.