Failure to Follow IV Antibiotic Orders Due to Incorrect Stop Date Entry
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for IV antibiotic therapy for one resident admitted with a UTI, urinary retention, Enterococcus faecalis bacteremia, and presumptive infective endocarditis. Hospital discharge documentation and an infectious disease (ID) physician note specified that the resident was to receive ampicillin 2 g IV every 4 hours through a specified January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly directed continuation of IV ampicillin at that dose and frequency until mid-January. On admission, the Admission Nurse entered the ampicillin order into the facility’s computer system with an incorrect stop date in December instead of the January stop date ordered by the ID physician. The electronic order was entered to run from the admission date with an end date in mid-December, and this incorrect order was confirmed by the RN Charge Nurse later that same day. The comprehensive care plan for antibiotic therapy also reflected the incorrect December stop date. As a result, the Medication Administration Record (MAR) shows that the resident received ampicillin IV every four hours only from the evening of admission through mid-December, at which point the medication was stopped per the erroneous end date. Because of the incorrect stop date and failure to reconcile the electronic order with the hospital discharge and ID orders, the resident did not receive ampicillin from mid-December until the medication was later resumed in late December, resulting in 59 missed doses of IV ampicillin. A Medication Occurrence Report documented this as an omitted dosage error caused by an admission order error and chart check error, noting that the infectious disease orders in the chart had the correct January stop date while the electronic order had the wrong December stop date. The DON confirmed that the Admission Nurse, the RN Charge Nurse, and the pharmacy consultant did not identify the discrepancy at the time of admission, and that the resident’s ampicillin was discontinued earlier than ordered, leading to the lapse in therapy.
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