F0755

D

Failure of Pharmacy Services and Consultant Pharmacist to Detect Incorrect IV Antibiotic Stop Date

Maryville, Tennessee Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure of the facility’s pharmaceutical services, including both the contracted pharmacy provider and the consultant pharmacist, to identify a transcription error in an IV antibiotic order, resulting in an incorrect stop date and an extended omission of ordered doses. A resident was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had hospital infectious disease orders for Ampicillin 2 g IV every 4 hours to continue through a specified date in January. The hospital discharge summary and infectious disease note documented Ampicillin 2 g IV every 4 hours with a stop date of January 13. The facility faxed the admission orders to the pharmacy provider, and the order was entered into the facility’s electronic system (PCC) on the day of admission as Ampicillin Sodium Solution 2 g IV every 4 hours, but with an incorrect stop date of December 13 instead of January 13. The order was confirmed in the system later that same day.

According to facility policy, the consultant pharmacist is responsible for providing consultation on all aspects of pharmacy services, including helping the facility develop processes for receiving and transcribing medication orders, and for performing a Medication Regimen Review (MRR) for every resident upon admission and at least monthly. The MRR is to include a thorough review of the medical record to prevent, identify, report, and resolve medication-related problems and errors, including omissions of ordered medications and documentation-related errors. The pharmaceutical services agreement with the pharmacy provider also requires that a licensed pharmacist review each resident’s drug regimen, including the medical chart, and report any irregularities to the attending physician, medical director, and DON. The agreement further states that the pharmacy will use an electronic system (PCC) to manage orders and MARs and that the pharmacy’s medical records department is responsible for ensuring that faxed orders match what is entered into PCC.

Despite these requirements, multiple review processes failed to detect the incorrect stop date. The pharmacy provider received the faxed admission orders on the day of admission, which correctly showed Ampicillin 2 g IV every 4 hours with a stop date of January 13, but the facility-entered order in PCC reflected a stop date of December 13. A pharmacist from the pharmacy provider performed a Drug Regimen Review on the day of admission and documented that the medications were reviewed with no recommendations. The consultant pharmacist completed an admission Pharmacy Drug Regimen Review three days later and also documented no recommendations or irregularities. The consultant pharmacist later stated that she reviews new admission medications to ensure physician orders match what is entered in PCC and that stop dates are part of this review, and acknowledged she should have identified an incorrect stop date. The pharmacy provider’s Director of Operations confirmed that the medical records department’s verification, completed three days after admission, should have identified the discrepancy between the faxed order’s January stop date and the December stop date entered in PCC but did not. As a result, the MAR shows the resident received Ampicillin IV every four hours from the evening of admission through December 13, when the medication stopped per the incorrect stop date, and the resident then missed 59 doses between December 13 and December 24, when the error was finally identified and the medication was resumed.

Interviews further clarified the sequence of events and the roles of involved staff. The DON stated that the admissions nurse entered the Ampicillin order with the incorrect December stop date, causing the medication to stop in error on that date. The DON confirmed that the error was not identified until December 24, at which time an order was obtained to resume the medication, and that the resident missed doses every four hours during the gap period. The Medication Occurrence Report documented the error as an omitted dosage due to an admission order error and chart check error, specifying that the wrong stop date was entered on admission and that infectious disease orders present in the record had the correct January stop date. The pharmacy provider’s Director of Operations confirmed that the faxed order to the pharmacy showed the correct January stop date, that the facility had entered a December stop date into PCC, and that the pharmacy’s medical records verification process should have detected and reported this discrepancy but did not. These combined failures by the facility’s pharmacy services and consultant pharmacist to identify and correct the transcription discrepancy led to the prolonged interruption of the resident’s ordered IV antibiotic therapy.