F0755

D

Failure to Administer and Document IV Antibiotics per Orders and Policy

San Diego, California Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure IV antibiotics were administered and documented in accordance with physician orders and facility policy for two residents. One resident was admitted with osteomyelitis and a chronic left foot ulcer and had an order for Cefepime 2 grams IV every 8 hours for infection. The IV administration record for this resident showed that on 3/17/26 the scheduled 7 a.m. Cefepime dose was documented as given at 10:34 a.m. by a licensed nurse (LN 1). During interview and record review, LN 1 acknowledged that he documented the 7 a.m. dose even though he had not actually administered the medication, stating he received report from the night shift RN that the medication had been given at 7 a.m. and later entered the documentation when he noticed it was missing.

The second resident was admitted with sepsis and unspecified valve endocarditis and had an order for Vancomycin 900 mg IV every 12 hours for MRSA bacteremia. The IV administration record indicated that on 3/11/26 the scheduled 8 a.m. Vancomycin dose was administered and documented by LN 1 at 12 p.m., four hours later than the prescribed time. LN 1 stated that the resident had a doctor’s appointment and was not in the facility at the scheduled administration time, and that the resident left by transportation at 9 a.m. for a noon appointment and returned at noon. LN 1 confirmed he did not notify the physician about the missed 8 a.m. dose, did not document a change of condition related to the missed dose, and acknowledged he should have obtained further orders to administer the Vancomycin late and could have administered the dose before the resident left for the appointment.

Additional interviews and policy review further described the expectations that were not followed. LN 1 stated that the medication administration process included verifying the right patient, right medication, and following physician orders, and that medications were to be given within one hour before or after the scheduled time, with physician notification if medications could not be given on time. Another licensed nurse (LN 2) stated she never documented another nurse’s medication administration and described this as wrong and not in line with standard practice, and also stated she reviewed residents’ appointment schedules at the start of her shift and would notify the physician if a medication was missed due to an outside appointment. The DON stated medications should be given in a timely manner, including for residents with outside appointments, and that it was not acceptable for LN 1 to document another nurse’s administration or to delay the Vancomycin dose without physician notification or change-of-condition documentation. The facility’s medication administration policy required medications to be administered in accordance with prescriber orders and within one hour of the prescribed time, and required the individual administering the medication to initial the MAR after giving each medication and record their signature and title in the medical record.