F0684

J

Failure to Administer Ordered IV Antibiotics, Recognize Change in Condition, and Arrange Appropriate Medical Transport

Warwick, Rhode Island Survey Completed on 02-18-2026

Penalty

Fine: $115,500

Summary

The deficiency involves the facility’s failure to administer ordered IV antibiotics, recognize and document a change in condition, notify a provider of that change, and arrange appropriate medical transport for a resident who was ultimately hospitalized and expired. The resident had been admitted with diagnoses including a UTI and had a care plan intervention to screen for sepsis and report positive screens or changes in vital signs and condition to a physician. A hospital discharge summary ordered Meropenem 1 g IV every eight hours for six days and documented that the resident was alert and oriented and receiving 1 L O2 via nasal cannula. Record review showed that three scheduled doses of Meropenem were not administered as ordered, and there was no evidence that the provider was notified of the missed doses.

On one evening, progress notes documented the resident as alert and oriented x3 with O2 saturation at 91% on oxygen via nasal cannula and a pulse of 96. During interview, the RN on the 11 PM–7 AM shift (Staff B) stated she found the resident confused, attempting to get out of bed, with the nasal cannula removed, short of breath, and with decreased O2 saturation. She reported increasing the oxygen flow from 1 L to 4 L, after which the O2 saturation improved, but she did not notify the provider because she did not consider this a change in condition and was unaware of the resident’s baseline. She also stated she told the oncoming nurse to keep an eye on the resident. The clinical record did not contain documentation that the resident had been found without the nasal cannula, that oxygen flow had been increased to maintain saturation, or that the resident was trying to get out of bed unassisted, and there was no documented communication of these findings to oncoming staff.

The oncoming RN (Staff C) documented that, later that morning, the resident had a change from baseline with decreased alertness, inability to follow simple commands or form words, and vital signs including BP 119/94, HR 126, RR 20, and O2 saturation 93% on 4 L O2. Staff C contacted the NP, who ordered the resident sent to the ED for evaluation, and transport was arranged with a non-medical transportation company. The Continuity of Care Acute Care Transfer Form completed by Staff C indicated the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and was experiencing a mental status change. The NP (Staff E) stated she was notified of the altered mental status and decreased O2 saturation and ordered the transfer but did not assess the resident in person, and she stated she would have expected the resident to be transported per facility policy for such a situation. The DNS reported there was no policy specifying the type of transportation for a resident with a change in condition and that mode of transport was considered a clinical decision.

Hospital documentation showed the resident arrived via non-medical transport with altered mental status, shortness of breath, and severe hypoxia, and was found to have hypercarbic hypoxic respiratory failure, sepsis, and influenza, and was transitioned to comfort measures and expired later that day. The Medical Director stated he would have expected IV antibiotics to be administered as ordered or the provider to be notified of missed doses, and that a decrease in O2 saturation should be identified as a change in condition with provider notification. He also stated he would have expected EMS transport for a resident with a change in mental status and decreased O2 saturation and reported being told that the family refused EMS because they wanted a specific hospital. The DNS stated the family member chose non-medical transport after being educated that non-medical transport could not provide medical support, while the family member stated they did not choose the mode of transportation, believed the transporters were EMTs, were not informed that the resident would not be monitored during transport, and were not made aware of the missed antibiotic doses.

The facility’s failures included: not administering three ordered doses of IV Meropenem and not notifying the provider of these missed doses; not identifying and documenting the resident’s nighttime confusion, removal of nasal cannula, shortness of breath, decreased O2 saturation, and need for increased oxygen as a change in condition; not notifying the provider at that time; and arranging non-medical rather than emergency medical transport for a resident with altered mental status, increased oxygen needs, and decreased O2 saturation. These failures were cited as placing the resident at risk for serious injury, serious harm, serious impairment, or death and were cross-referenced to F695, F726, F760, and F842.