Failure to Obtain and Administer Ordered IV Antibiotic and Notify Physician When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely acquisition and administration of a prescribed IV antibiotic and to follow its own policy for unavailable medications. Facility policy on unavailable medications, last reviewed December 8, 2025, requires nursing staff, in conjunction with the contracted pharmacy, to make every effort to ensure ordered medications are available, and upon learning a medication is unavailable, to notify the physician, obtain a new order and discontinue the prior order, or obtain a hold order. For one resident, a physician’s order for Vancomycin IV 1000 mg/200 ml every 12 hours for MRSA was initiated on March 20, 2026. An admission progress note that day documented the resident’s admission with a right foot abscess and MRSA and indicated that the physician’s orders were reviewed with no clinically significant order issues identified. A review of the medication administration record for March 2026 showed that the resident did not receive the ordered Vancomycin IV doses scheduled for 9:00 PM on March 20 and 9:00 AM on March 21. The clinical record contained no documentation that staff notified the physician that the Vancomycin IV was not available for administration. During interviews, the NHA and DON confirmed that the resident did not receive the Vancomycin IV as ordered because the medication was not available at those scheduled times and that they were unable to provide documentation of physician notification regarding the unavailability of the antibiotic. This resulted in two missed administrations of the prescribed antibiotic medication for this resident.
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