Failure to Clarify and Follow Medication and IV Fluid Orders
Penalty
Summary
Facility staff failed to ensure that physician orders were clarified, followed, and that ordered medications and treatments were administered to a resident diagnosed with Influenza A and bacteremia. The resident was diagnosed with Influenza A and had an order entered for Tamiflu 30 mg PO BID for 5 days, which was discontinued the same day and re-entered later that night; however, the medication was never administered according to the MAR. Documentation showed the physician was notified late in the evening on the day of the order that the medication was not received, but there was no documentation that the pharmacy was contacted or that the physician was notified when the medication was still not received the following day. During interviews, the LPN Unit Manager stated that medications are typically received within 24 hours or within a 4-hour window for STAT orders, and the physician and NP later reported they were not aware that the Tamiflu had not been administered. The same resident had a critical blood culture result positive for gram-positive cocci, and was ordered Vancomycin 750 mg IV BID for 14 days for bacteremia. The resident received three doses, and a Vancomycin trough level was reported as high, leading to a dose reduction to Vancomycin 500 mg IV BID for 14 days. The resident did not receive any doses of the reduced Vancomycin prior to being sent to the emergency room, and there was no documentation that the physician or pharmacy were notified that the lower dose was not administered. Additionally, the resident had an order for 0.9% NaCl IV q shift that did not specify the volume in milliliters to be infused each shift, and this incomplete order was not clarified. A later order for 1 liter NaCl IV on specific evenings at 100 ml/hr directed nurses to document the total amount of IV fluid given each shift, but the MAR showed that nurses were not documenting the volume administered. The DON acknowledged that the amount of fluids given should be written in the notes, and the LPN Unit Manager stated that if a medication is not available on site, they would obtain an equivalent and call the pharmacy for a STAT dose.
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