Failure to Administer Prescribed Antibiotic Following Physician Order
Penalty
Summary
A deficiency occurred when a resident who was admitted for aftercare following a fractured left ankle did not receive a prescribed antibiotic for a suspected surgical site infection. The surgeon ordered Bactrim DS to be administered twice daily for ten days, starting on 3/3/25, after a follow-up visit raised concerns about infection. However, the antibiotic was not administered as ordered. The failure was traced to a breakdown in the facility's process for handling physician orders received via fax. The surgeon's progress note, which included the antibiotic order, was faxed to the facility and received by medical records staff, but it was not provided to the clinical staff as required. The Director of Nursing confirmed that the process in place to start antibiotics within four hours of receiving an order was not followed, resulting in the resident not receiving the medication as prescribed.