Failure to Accurately Document and Administer Ordered Antibiotic
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered antibiotic was not administered as prescribed. The resident was admitted with diagnoses including UTI, vascular dementia, protein-calorie malnutrition, pneumonia, and anxiety disorder. A physician’s order dated 1/19/2026 directed that amoxicillin-potassium clavulanate 875 mg-125 mg be given by mouth every 12 hours for seven days for a bacterial infection, and the care plan initiated the same day identified this medication for treatment of pneumonia with an intervention to administer medications as ordered and assess for complications. On 1/20/2026, the MAR showed that the resident was documented as having received the ordered amoxicillin-potassium clavulanate at 9 a.m. However, during interview and concurrent record review, the LVN assigned to the resident that day stated that the resident was not eating breakfast and would not open his mouth, so the morning medications, including the antibiotic, were not actually given. The LVN acknowledged that she signed off seven medications on the MAR as given even though they were not administered and did not enter any note indicating that the medications were signed off in error. She further stated that she should have documented the error and notified her supervisor and the physician when the resident refused the antibiotic. The DON confirmed during interview and record review that if a resident refuses or is unable to take medications, the nurse should not sign them as given but should document the refusal and the reason, and that the MD must be notified within the shift of a missed or refused antibiotic. The DON stated that the documentation on the MAR was inaccurate because the medications were not given and that the MD was not notified of the missed antibiotic, although the MD was notified of the resident’s lethargy as a change of condition. Review of facility policies showed that charting must be objective, complete, and accurate, and that medication refusal must be documented with physician notification the same day for antibiotics, which did not occur in this case.
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