Failure to Administer Prescribed Antibiotics After Hospital Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including paraplegia, a stage four pressure ulcer, acute osteomyelitis, and scoliosis, did not receive prescribed antibiotics following discharge from the hospital. The resident was discharged from the hospital with orders for two antibiotics, Linezolid and Cipro, to be administered twice daily for several days. Upon readmission to the facility, the antibiotics were not promptly administered as prescribed. Interviews and record reviews revealed that the process for entering hospital discharge medication orders into the facility's electronic system was not consistently followed. The charge nurse on duty did not input the orders, and there was confusion among staff regarding the presence of the antibiotics in the facility's emergency kit and the process for obtaining medications from the pharmacy. The resident himself brought the missing antibiotics to the attention of the staff, prompting further investigation and eventual notification of the nurse practitioner. Facility staff, including the LVN, charge nurse, and DON, acknowledged that the resident did not receive the antibiotics as ordered and described the process failures that led to the omission. The facility's medication reconciliation policy required verification and timely ordering of medications upon admission, but these steps were not completed, resulting in the resident missing doses of critical antibiotics.