Missed Vancomycin Doses and Lack of Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV Vancomycin doses were not administered as prescribed and the physician was not notified of the missed doses. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder. The February 2026 MAR shows that Vancomycin 1750 mg/350 ml every 12 hours for infection was not given on multiple scheduled administrations: 2/26 at 9:00 PM, 2/27 at 9:00 PM, 2/28 at 9:00 AM, and 2/28 at 9:00 PM. An LPN stated she did not know why the Vancomycin was not given on those days, speculating that on the admission date it was probably not available, that on one date the resident went to the hospital after calling 911, and that on another date the medication might have been on hold pending blood test results, but she did not provide a clear reason for each missed dose. Laboratory data show that a Vancomycin trough drawn on 2/28/26 was reported as an alert low value of 3.6 (normal 10–20), with the result communicated to facility staff on the same day at 2:52 PM. The facility’s process, as confirmed by staff, was to notify the pharmacy after receiving such results. The next progress note entry, dated 3/1/26 at 3:19 PM, documents a call from the pharmacy with instructions to continue the same Vancomycin dose and obtain additional labs, and staff confirmed that a Vancomycin dose was administered on 3/1/26 at approximately 9:30 AM before the pharmacy’s recommendations based on the 2/28/26 lab were received. Pharmacy packing slips show that a total of 8 Vancomycin doses were delivered between 2/26 and 3/3, while the MARs for February and March 2026 document administration of only 5 doses. Progress notes from 2/27 through 3/1 do not contain any documentation that the physician was notified of the missed Vancomycin doses.
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