Failure to Accurately Transcribe Antibiotic Order Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and initiate an antibiotic order as written by the physician for one resident. The resident had diagnoses including gas gangrene and a foot ulcer and was discharged from the hospital with an order for amoxicillin-pot clavulanate 875-125 mg, one tablet twice daily, to start on the day of discharge and stop on a specified later date. The facility’s physician order matched the hospital discharge order, including the start and stop dates. However, the January and February MARs listed the start date as the day after admission, with the first scheduled administration on the evening shift, resulting in the evening dose on the day of admission and the morning dose the following day not being given. The resident’s MDS indicated no cognitive impairment and documented that the resident was administered an antibiotic. Interviews confirmed that the antibiotic was delivered to the facility on the day of admission and that medications are expected to start on the day of admission unless a different start date is ordered. The pharmacist stated that medications should start on the day of admission in the absence of a specific alternate start date. Nursing staff reported that medications appear on the MAR based on the transcribed start date and confirmed that the first dose of the antibiotic was not given until the evening of the day after admission, acknowledging that it should have started the prior day. The NP stated that medications should start on the day of admission unless otherwise specified and that the provider should be notified of missed doses, but did not recall being notified of the two missed doses. The DON acknowledged that the order was not transcribed accurately, as the start date should have been the day of admission, which resulted in two missed doses, contrary to the facility’s policy requiring accurate and timely transcription of medication orders including correct start and stop dates.
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