HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure that an antibiotic was given as ordered by the physician to Resident #11, one (1) of 20 residents reviewed.


Findings include:


Record review revealed that Patient #11 was a 75 year old admitted on 07/11/11 with Respiratory Failure. During this admission he was found to have a Candida (yeast) Urinary Tract Infection. On 08/23/11 at 10:10 a.m. a physician's order was written for "3. Start PO (by mouth) Fluconazole 100 mg (milligram) q (every) 24 hours".


Review of the resident's 08/23/11 Medication Administration Record (MAR) revealed that the order was hand written on the MAR as "Start PO Fluconazole 100 mg q 24 hour", but was not signed off as having been given. The order written by the physician had no start or end date. The normal course of this drug is seven (7) days and there is an automatic stop date in seven (7) days.

Review of the resident's 08/24/11 MAR revealed that the medication was handwritten as "Fluconazole 100 mg P.O. q 24 hrs (hours)" and was initialed by a nurse as being given to Resident #11 at 9:00 a.m.. On 08/27/11 the medication was listed on the MAR with the statement "No Order." There was no documented evidence that Resident #11 got the ordered Fluconazole 100 mg on 08/25, 08/26, 08/27 or 08/28/11.


There was no documented evidence that this medication error was identified by the Nursing or Pharmacy Departments until 08/29/11. Review of the Medical Dispense Drug Transaction Log revealed that after the medication error was identified Fluconazole 100 mg was signed out for Resident #11 on 08/29, 08/30, 08/31, 09/01, 09/02 and 09/03/2011.


On 09/22/11 an interview with the Director of Quality/Infection Control revealed, "The order (for the Fluconazole 100 mg) was not faxed to the Pharmacy. This process issue causing a medication error is going to be tracked by the Quality Committee and reported to all involved parties."

Based on review of employee files, the facility failed to ensure that three (3) of 11 employees reviewed received Tuberculosis (TB) Skin Testing annually (unless previously positive).


Findings include:


Review of 11 employee files revealed that two (2) employees were late getting their TB tests and one (1) employee had no Tuberculosis screening around the date when due.