Failure to Administer Ordered IV Antibiotic for Infected Foot Ulcer
Penalty
Summary
Facility staff failed to administer a prescribed intravenous (IV) antibiotic to a resident with an infected diabetic ulcer of the right foot. The resident, who was cognitively intact and required significant assistance with activities of daily living, had a deteriorating foot wound with increased edema and purulent drainage. After laboratory results identified multiple organisms in the wound, a wound care nurse practitioner ordered IV Linezolid to begin on a specific date, with the medication and IV access available at the scheduled start time. Despite these preparations, the resident did not receive any doses of the antibiotic as ordered. The initial dose was missed even though the IV access and medication were ready, and subsequent doses were not administered due to the IV being dislodged and not promptly replaced. Nursing notes indicated ongoing delays, and the antibiotic was ultimately discontinued on the recommendation of a consulting physician before any doses were given. Facility leadership was informed of these findings and did not provide comments or express concerns during the final interview.