Failure to Provide Prescribed Antibiotics Upon Readmission
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including paraplegia, a stage four pressure ulcer, acute osteomyelitis, and scoliosis, was not provided with prescribed antibiotic medications following discharge from the hospital. The resident was discharged with orders for two antibiotics, Linezolid and Cipro, to be administered for several days. Upon readmission to the facility, the antibiotics were not provided as ordered, and the resident reported not receiving the medications when asked. Interviews and record reviews revealed that the process for entering hospital discharge orders into the facility's electronic system was not consistently followed. The charge nurse on duty did not input the orders, and there was confusion among staff regarding the responsibility for ensuring the medications were available and administered. The resident had to inquire about his antibiotics, prompting staff to investigate and eventually identify the missing orders. It was noted that one of the antibiotics was available in the facility's emergency kit, but the other was not, and there were delays in obtaining it from the pharmacy. Staff interviews indicated that the breakdown in communication and order entry led to the resident missing doses of his prescribed antibiotics. The facility's policy emphasized the importance of treating residents with respect and dignity, including the right to receive medications as ordered. The failure to provide the antibiotics as prescribed constituted a violation of these rights and the facility's own policies.