Failure to Assess Continued Need for Prophylactic Antibiotic
Penalty
Summary
The facility failed to assess the continued need for a prophylactic antibiotic for a resident with chronic osteomyelitis, diabetes, and constipation. The resident, who was cognitively intact, had been receiving Ciprofloxacin for chronic osteomyelitis for several years and expressed a desire to discontinue the medication. Despite this request, the provider ordered the continuation of the antibiotic and requested follow-up consultations with Infectious Disease (ID) and Endocrinology to evaluate the necessity of ongoing antibiotic therapy. However, there was no documented evidence that these consults were scheduled or completed, and the resident continued to refuse the medication on multiple occasions. Interviews with facility staff revealed that the process for scheduling specialist appointments was not followed, as the responsibility had shifted from medical records staff to unit managers, leading to missed appointments. The Director of Nursing (DON), who also served as the Infection Preventionist, was unaware of the resident's request to discontinue the antibiotic and did not track residents on prophylactic antibiotics. The lack of coordination and follow-through resulted in the resident not receiving the necessary specialist evaluations to determine the appropriateness of continued antibiotic use.