Delay in Initiation of Prescribed Antibiotic for Cellulitis
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from significant medication errors. The resident, who had a history of diabetes, a serious right ankle fracture, and dementia, was admitted to the facility and later sent to the emergency room with complaints of abdominal pain and right third toe redness and swelling. The ER diagnosed early cellulitis of the right third toe and prescribed an antibiotic (Keflex 500 mg four times daily for 7 days). The ER instructions included prompt initiation of the antibiotic. Despite these instructions, the facility delayed entering the antibiotic order into the Medication Administration Record (MAR) until the day after the ER visit, and the first dose was not administered until two days after the ER visit. Interviews with facility staff confirmed that new orders are not always processed immediately, and the facility's own policy requires timely documentation and transcription of new medication orders. This delay resulted in the resident not receiving the prescribed antibiotic as promptly as required.