F0760

D

Omission of 59 IV Ampicillin Doses Due to Incorrect Stop Date Entry and Missed Chart Checks

Maryville, Tennessee Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when 59 ordered doses of IV ampicillin were omitted. The resident was admitted from the hospital with diagnoses including UTI, Enterococcus faecalis bacteremia, sepsis secondary to UTI, anemia, and a presumptively infected left atrial thrombus. Hospital infectious disease documentation and the discharge summary specified that the resident was to receive ampicillin 2 g IV every 4 hours and ceftriaxone (Rocephin) 2 g IV every 12 hours through a specific 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 indicated that both IV antibiotics were to continue concurrently through mid-January.

On admission, the Admission Nurse entered the IV antibiotic orders into the facility’s electronic system (PCC). While the ceftriaxone order was entered with the correct stop date, the ampicillin order was entered with an incorrect stop date in December instead of the January date ordered by the infectious disease physician. The RN Charge Nurse confirmed the admission orders in the electronic system against the physical hospital orders but did not identify the discrepancy in the ampicillin stop date. A 24-hour chart check was then completed by an LPN, who also failed to detect that the ampicillin stop date in the computer did not match the physician’s written orders. The comprehensive care plan that was initiated likewise reflected the incorrect, shortened ampicillin date range.

As a result of the incorrect stop date and the missed verification opportunities, the resident received IV ampicillin every four hours only from the evening of admission through the early evening of the erroneous December stop date. After that point, the ampicillin was automatically discontinued in the system, and the resident did not receive any further doses until the medication was later restarted. Review of the MAR showed that the resident missed 59 doses of IV ampicillin between the erroneous discontinuation date and the date the order was resumed, while ceftriaxone continued to be administered as ordered. The medication occurrence report identified the error as an omitted dosage caused by an admission order error and chart check error, and the DON confirmed that the facility’s medication verification processes were not followed, resulting in the resident not receiving ampicillin as ordered during that period.