Failure to Administer Ordered IV Antibiotic Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV antibiotic therapy was not administered as prescribed. The resident was admitted with a diagnosis that included a UTI and had a hospital discharge order for Meropenem 1 g in 50 mL normal saline IV every eight hours for six days. The facility’s physician order reflected Meropenem IV 1 g in 50 mL normal saline three times a day for a complicated UTI through a specified end date. Record review showed the resident missed three doses of the ordered Meropenem IV. The facility had received a complete IV E‑kit that contained Meropenem IV 1 g vials and 100 mL normal saline, and the PharMerica Genesis Master E‑Kit Contents List confirmed these items were available. During interviews, an RN reported she did not administer the antibiotic because it was not available in the exact 50 mL normal saline bag specified, despite knowing Meropenem and 100 mL normal saline were present in the E‑kit. She stated she asked the Unit Manager RN how to administer the medication and was told it could not be given without the correct size saline bag. The pharmacist confirmed Meropenem IV 1 g was available in the E‑kit and stated he would have expected the facility to call the pharmacy to clarify use of the 100 mL normal saline. The IV E‑kit utilization form showed no evidence that Meropenem or normal saline was removed from the kit, and the electronic shipping manifest showed that Meropenem and 50 mL normal saline from the pharmacy did not arrive until later. The DON and Medical Director both acknowledged that Meropenem IV 1 g and 100 mL normal saline were available in the E‑kit and that three doses were missed, and there was no documentation that a provider was notified of the missed doses. The resident was later sent to the hospital after missing three of five doses of the IV antibiotic and was diagnosed there with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and subsequently expired after being transitioned to comfort measures.
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