Failure to Administer Ordered Antibiotic When Available in Emergency Kit
Penalty
Summary
The facility failed to administer a prescribed antibiotic in accordance with professional standards and physician orders for one resident. The resident had been admitted with diagnoses including non‑traumatic intracerebral hemorrhage and H. pylori gastritis. The hospital After Visit Summary dated 3/17/26 showed metronidazole 500 mg every 6 hours, with the last hospital dose given at 12:12 p.m. The facility’s Order Summary Report starting 3/17/26 ordered metronidazole 500 mg via PEG tube every 6 hours for H. pylori gastritis. Review of the March 2026 MAR showed that the resident did not receive the scheduled metronidazole doses on 3/17/26 at 6 p.m. and 3/18/26 at 12 a.m. During interviews and concurrent record review, the Infection Preventionist confirmed that the medication had not been given, as documented in Administration Notes on 3/17/26 at 7:45 p.m. and 3/18/26 at 12:32 a.m., which indicated the medication was pending pharmacy delivery. In a medication room observation, the Infection Preventionist checked the emergency medication kit (e‑kit) and found it contained metronidazole, and stated the nurse should have used the e‑kit to administer the scheduled antibiotic if available. The DON also stated that the nurse should have used the ordered medication from the e‑kit. The facility’s undated “Administering Medications” policy stated that medications are to be administered in a safe and timely manner, as prescribed, and in accordance with prescribed orders, including any required time frame.
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