Failure to Administer IV Antibiotics and Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to administer prescribed intravenous antibiotics as ordered for three residents and did not ensure wound treatments were completed and documented for one resident. For one resident with a history of prosthetic hip infection and recent surgery, the required six-week course of IV antibiotics was not provided after admission. Documentation showed that only one dose was given, and subsequent doses were missed or discontinued without proper follow-up or clarification with the prescribing physician. There was also a lack of documentation for wound care treatments on several days, and no evidence of communication with the surgeon or infectious disease specialist regarding the antibiotic regimen. Another resident with a chronic non-pressure ulcer and osteomyelitis had multiple missed doses of IV Cefazolin, with no documentation explaining the omissions. The resident's care plan required administration of antibiotics and wound treatment as ordered, but the medication administration record showed several unsigned doses, and the DON was unable to provide reasons for the missed doses. A third resident with osteomyelitis and other comorbidities also had several missed doses of IV Ampicillin-Sulbactam, again with no documentation for the missed administrations. The care plan for this resident included administration of antibiotics per physician orders, but the medication administration record indicated multiple unsigned doses. Interviews with the DON confirmed the lack of documentation or explanation for these missed medications.