Failure to Administer Prescribed Medications for Infection and COVID-19
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration of prescribed antibiotics and antiviral medications. For one resident with multiple diagnoses including a recent below-the-knee amputation, diabetes, and pressure ulcers, a physician ordered intravenous Flagyl for a wound infection. The medication was not available and was never administered, with no documentation of physician notification or follow-up. The resident's condition deteriorated, and the wound doctor was not informed of the missed doses until after the resident was hospitalized and subsequently expired. The facility's staff, including the DON and corporate nurse, were unable to explain why the medication was not given as ordered. Another resident with Alzheimer's disease, diabetes, and COVID-19 was prescribed Paxlovid for a confirmed COVID-19 infection. Although the medication was delivered as a single unit from the pharmacy, the resident received only 3 out of 10 scheduled doses, with no documentation explaining the missed doses. The DON and corporate nurse confirmed that the medication should have been available and could not account for the failure to administer it as prescribed. The records lacked evidence of appropriate follow-up or communication regarding the missed medication doses.