Significant Medication Error Involving Wrong Antibiotic Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors when a nurse did not administer medication as prescribed by the physician. Review of a complaint and the resident’s medication administration audit showed that on 12/6/25 at 6 PM, the resident received meropenem, a broad-spectrum carbapenem antibiotic used to treat severe bacterial infections, instead of cefepime, a fourth-generation cephalosporin antibiotic that had been ordered by the physician for a urinary tract infection. This constituted a failure to follow the five rights of medication administration, specifically administering the wrong medication, and resulted in the resident receiving a medication that was not prescribed, although no negative outcome was documented for the resident. The deficiency was identified through observation, record review, and interviews, which confirmed that the medication was not given as ordered and that the resident’s medication administration record reflected the administration of an unprescribed antibiotic for the urinary tract infection.
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