F0755

D

Incorrect IV Antibiotic Infusion Rate Due to Nurse Misinterpretation of Pharmacy Label

San Antonio, Texas Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate administration of an IV antibiotic in accordance with pharmacy directions for one resident. The resident was an elderly male with diagnoses including bacteremia, MRSA infection, peripheral vascular disease, multidrug-resistant organism, and septicemia. His admission and annual MDS assessments showed a decline from cognitively intact (BIMS 15) at admission to severely cognitively impaired (BIMS 0) at the time of the annual assessment. He had active orders for cefazolin sodium 2 g IV every 8 hours for MSSA to both lower extremities, with the pharmacy label specifying CEFAZOLIN 2G/50 ML-DEXTROSE to be activated, mixed, and infused intravenously over 30 minutes at a rate of 100 mL/hr every 8 hours. The MAR reflected this IV antibiotic order and documented administration by RN A.

During surveyor observation, the resident was noted to have a PICC line in the left upper arm and reported no issues with IV medication administration. Later observation showed RN A administering the cefazolin IV and setting the infusion pump rate at 75 (mg/hr), despite the IV bag label indicating administration at 100 (mL/hr). In interviews, the DON acknowledged that administering at 75 versus 100 would result in a slower rate and stated she expected nurses to check the rate, noting that the rate was printed on the IV bag and set by the pharmacy because hospital discharge orders did not include a rate. RN A stated the medication was to be titrated over one hour and reported misinterpreting the prescription, believing 100 referred to volume and 75 to the rate. MD B stated that administering the medication at 75 instead of 100 was medically acceptable and would only prolong the administration time. No facility policy on medication administration was requested for review.