Failure to Clarify Conflicting Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to clarify and implement admission medication orders for one resident when the resident was admitted from the hospital. The hospital discharge packet dated 12/13/25 included a discharge order for Ceftriaxone 2 grams IV every 24 hours through 1/2/26, but the resident’s December 2025 MAR shows that this IV antibiotic order was not initiated on the admission date. The DON stated that the resident returned from the hospital on hospice and, to his knowledge, did not have IV access and was not receiving IV antibiotics. Upon reviewing the hospital discharge packet, the DON noted that in one section the antibiotics were documented as discontinued, but in another section Ceftriaxone was listed under discharge orders, and acknowledged that the admitting nurse should have called to clarify the conflicting orders. The facility’s policy on physician orders for medications or treatments, dated 6/2022, requires that any dose or order that appears inappropriate considering the resident’s age, condition, or diagnosis be verified with the attending physician, which was not done in this case.
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