Failure to Coordinate and Administer Ordered IV Vancomycin with Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received IV vancomycin therapy for sepsis and osteomyelitis in accordance with professional standards and physician orders. The resident was discharged from the hospital with diagnoses including sepsis secondary to a right lower extremity diabetic wound infection with osteomyelitis, MRSA and enterococcus bacteremia, and was prescribed IV vancomycin to be given with hemodialysis on specified days through a set end date. On admission to the facility, orders were entered for vancomycin 1.25 g IV on Tuesday, Thursday, and Saturday, with instructions to send the IV antibiotic to dialysis and for the dialysis center to monitor vancomycin and related labs. The care plan initiated shortly after admission documented that the resident was on IV antibiotic therapy related to sepsis and that the treatment was to be administered at the hemodialysis center, with interventions to administer medication as ordered and monitor for side effects. Despite these orders, there was no documentation in the resident’s progress notes that the IV antibiotic was administered or not administered during the first scheduled dialysis session after admission. The NP/PA note later documented that the resident was receiving IV vancomycin with hemodialysis and tolerating therapy, but subsequent documentation revealed that the dialysis center did not administer the vancomycin because they had not received appropriate orders and could not accept medication brought in by the resident. An NP/PA note and eMAR entry documented that the dialysis center was unable to administer the vancomycin due to lack of approval by the dialysis physician and pharmacy, and that the scheduled dose was missed. The attending physician was notified of the missed dose, and the facility awaited further orders and clarification, but the resident reported that he had attended two dialysis sessions without receiving his IV antibiotics. Interviews and record review showed that the facility did not coordinate with the dialysis center prior to the resident’s first dialysis visit to verify that the IV antibiotic could be administered there, and the dialysis center reported they were unaware of the need for IV antibiotics until the resident arrived with the medication. The dialysis center’s representative stated that their policy required cultures, a physician order, and medication delivered directly to the center, and that there had been no prior communication from the facility about the resident’s IV antibiotic needs. The admission LPN stated she entered the vancomycin orders and assumed that sending the unopened medication and order with the resident would result in administration at dialysis, and acknowledged that there should have been appropriate MAR coding and progress notes if treatment was not given. The DON confirmed that there was no documentation regarding the vancomycin administration issue until several days after the first missed dose, acknowledged that the resident missed two doses, and that the MAR for the first missed treatment was marked with an “X” without a code, making it appear as though nothing was brought or given. The facility also lacked a Quality of Care or Coordination of Care policy, while existing policies required accurate implementation of physician orders and complete documentation of care and treatment.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.