F0757

D

Unnecessary Medication and Antibiotic Use Due to Transcription Error and Lack of Stewardship Criteria

St Clairsville, Ohio Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in medication management that resulted in residents receiving unnecessary or incorrect medications. For one resident with anoxic brain damage, epilepsy, depression, anxiety, insomnia, hypertension, history of methadone poisoning, and migraines, neurology orders from an outside appointment directed an increase in Baclofen, continuation of Keppra, Prozac, and Topamax, and initiation of Elavil at bedtime. Nursing staff transcribed these orders onto the MAR as Vistaril 25 mg at bedtime instead of Elavil, and the resident received Vistaril from mid-December through late December despite the neurologist’s written order specifying Elavil. The DON reported that two nurses reviewed the neurology orders and believed the medication name was Vistaril, leading to the incorrect transcription and administration of a medication not ordered by the neurologist.

A second deficiency involved antibiotic use for another resident with vascular dementia, severe protein-calorie malnutrition, and congestive heart failure. After a fall and transfer to the ER for shoulder pain, the resident returned with a diagnosis of UTI and a new prescription for cephalexin 500 mg every eight hours for five days. An antibiotic assessment completed the next day documented that the resident did not meet criteria for antibiotic use and that the primary physician advised waiting for urine culture results. Despite this, the resident was seen by a nurse practitioner two days later and the antibiotic was continued. The facility’s records contained no urine culture results or ER records from the visit, and the facility’s Antibiotic Stewardship policy did not include requirements that antibiotics meet specific criteria for use.