Failure to Accurately Reconcile and Administer Hizentra and Amoxicillin
Penalty
Summary
The deficiency involves the facility’s failure to reconcile and administer prescribed medications according to professional standards for two residents. One resident with respiratory failure, common variable immunodeficiencies, and Crohn’s disease had a standing order for weekly subcutaneous Hizentra, supplied by a specialty pharmacy and stored in the medication room refrigerator. The MAR from October through March showed multiple weeks where Hizentra was documented as “not available,” interspersed with a few entries indicating administration by nursing staff. The resident reported not receiving Hizentra for months after a hospital stay in November, and the specialty pharmacy confirmed the last shipment of a one‑month supply was delivered in early September, with no subsequent orders or contacts from the facility. The Administrator acknowledged the facility did not keep records of specialty pharmacy deliveries and could not confirm that doses documented as given on the MAR were actually administered. For this same resident, nursing staff interviews revealed inconsistencies between staff recollections and pharmacy records. One nurse stated they administered Hizentra on a December date as documented on the MAR and recalled sometimes the medication was not available, while another nurse could not recall one of the documented administration dates but reported obtaining the medication from the storage room refrigerator on a later date. Despite these MAR entries, the specialty pharmacy reported no shipments after September and no calls from the facility requesting additional medication. The facility lacked a tracking system for specialty pharmacy deliveries, and there was no documentation to reconcile the discrepancy between the MAR entries, staff statements, and the pharmacy’s delivery history. A second resident, a long‑term resident with cardiac and kidney disease and moderately impaired cognition, experienced a failure in timely initiation of a prescribed antibiotic. After hospitalization for severe sepsis related to cellulitis of the left lower extremity, the infectious disease consultant and the hospital AVS directed that Amoxicillin 1 g orally three times daily be started and continued for four weeks. The resident returned to the facility, and the admitting LPN described a process in which hospital discharge orders are entered and then reviewed by a unit manager and a nursing leader. However, the MAR showed that Amoxicillin was not administered by the facility until several days after readmission. Review of the electronic orders revealed that the LPN had entered the Amoxicillin with an incorrect future start date, and the order was not corrected until identified by the NP and entered by an RN several days later. The DON and ADON confirmed that the medication was not ordered correctly and that the multiple reconciliation steps in the admission process were not performed accurately.
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