Failure to Implement Revised IV Antibiotic Orders and Notify Physician of Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received IV antibiotics as ordered and to notify the physician of the resulting medication errors. The resident had multiple serious diagnoses, including wound infection, osteomyelitis, DM, renal failure, CHF, MRSA in a right heel wound, and sepsis likely due to a necrotic right heel wound with palpable bone and cellulitis. Hospital discharge instructions and an Infectious Disease (ID) Outpatient Antibiotic Order dated 02/17/26 initially directed Daptomycin 750 mg IV every 48 hours and Piperacillin-Tazobactam 4.5 g IV twice daily until 03/14/26, with further antibiotic orders to come from the ID clinic after the first appointment. At an ID clinic visit on 02/28/26, the provider issued a Final Report ID Outpatient Antibiotic Order, which changed the frequency and duration of both antibiotics: Daptomycin 750 mg IV every 24 hours until 03/17/26 and Piperacillin-Tazobactam 4.5 g IV every eight hours until 03/17/26. The facility was directed to use this new order. However, the resident’s EMAR for February and March 2026 continued to show the original orders—Daptomycin 750 mg IV every 48 hours and Piperacillin-Tazobactam 4.5 g IV twice daily—starting 02/18/26, and these orders were not discontinued until 03/05/26 after the resident went to the hospital. The orders were not updated to reflect the increased frequency specified by the ID provider. On 03/05/26, during a follow-up ID office visit, the provider documented that the resident had not received the corrected medication frequency for either antibiotic. The provider also noted that the PICC line dressing, which was to be changed weekly and as needed, was loose and had not been changed since 02/17/26, and that the PICC line clave connector had been exposed for an unknown amount of time. The physician was notified, the PICC line was removed, and the resident was sent to the hospital for worsening wounds and concern for blood infection. Subsequent observation on 03/23/26 showed a nurse administering IV medication via the PICC lumen, but the underlying deficiency centered on the facility’s failure to update and implement the revised ID antibiotic orders and to notify the physician of the medication errors.
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