Resident Did Not Receive IV Antibiotic at Ordered Frequency
Penalty
Summary
A resident admitted with orthopedic aftercare needs, an acquired absence of the left great toe, and type 2 diabetes had hospital discharge orders for IV Cefazolin 2 g every 8 hours for 50 days, with the last hospital dose given the morning of admission. Upon admission, facility staff entered the IV antibiotic order incorrectly into the system as 2 g IV every 24 hours/once daily instead of every 8 hours, and no additional dose was administered on the day of admission after the morning hospital dose. The Medication Administration Record showed the resident received only one 2 g dose on the day after admission, rather than the ordered every-8-hour regimen. Progress notes documented that a medication error occurred when the IV antibiotic was entered incorrectly and scheduled every 24 hours instead of every 8 hours, and that the resident reported not receiving the antibiotic the night of admission and told nursing staff multiple times that it was supposed to be given every 8 hours. The DON stated that the facility obtained medication orders from the hospital, that nursing managers were to review medications and orders within 72 hours of admission, and that nurses were instructed to have nursing management double-check all ordered medications. The DON reported that the admitting nurse misread the hospital order, leading to the incorrect frequency being entered and the resident not receiving the IV antibiotic as ordered every 8 hours.
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