F0684

J

Failure to Follow Antibiotic and Wound Care Orders Leading to Sepsis and Death

Salem, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and adequately monitor and treat worsening bilateral lower extremity venous wounds and infections for a resident with multiple comorbidities, including lymphedema, cellulitis of both lower limbs, MRSA infection, pseudomonas, severe sepsis with septic shock, diabetes with neuropathy, and chronic edema. The resident had intact cognition per a BIMS score of 15 and an active diagnosis of wound infection and venous/arterial ulcers on the MDS. The care plan documented sepsis and a history of bilateral lower extremity wounds, with approaches specifying treatment and antibiotics per order and to report ineffective treatment or adverse effects to the physician. Despite this, multiple antibiotic and wound care orders from a consulting wound clinic and from a hospital were not entered into the electronic record, not available on the POS or MAR, or not administered as ordered.

The consulting wound clinic ordered IV vancomycin 1 g BID for 14 days, but facility staff documented they could not administer IV medications every 12 hours due to lack of RNs on night shift. The order was changed to vancomycin 1 g daily and later to 1.5 g daily, yet the MAR showed multiple days where vancomycin was not administered, marked as the resident being unavailable or the medication being on hold. Additional clinic orders for Bumex, Levaquin, and Cipro were not found on the MAR or POS. Later, the clinic ordered levofloxacin 750 mg daily for 10 days and a Medrol dose pack; staff documented awareness of the resident’s allergy to levofloxacin, faxed the clinic for clarification, and noted that the antibiotic order was not clarified, but the levofloxacin order never appeared on the MAR or POS. Another clinic order for Invanz 1 g daily for 14 days for ESBL UTI was documented in progress notes, but Invanz was not present on the MAR or POS, and multiple nurses stated they did not remember the resident ever receiving Invanz. Staff notes show repeated attempts to contact the clinic and pharmacy about missing Invanz orders, but also show that follow-up was not consistently completed or clearly handed off.

Wound care orders were also not consistently implemented as written. The clinic and hospital ordered specific wound care regimens, including Dakins 0.25% solution wet-to-dry dressings, Vashe wound solution, exufiber dressings, ABD pads, kerlix, and ACE wraps. The MAR documented numerous instances where ordered treatments were not administered due to drug or item unavailability, with nurses substituting wound cleanser and available dressings instead of Dakins, Vashe, exufiber, or kerlix. Staff interviews confirmed that Dakins solution, Vashe, exufiber, and kerlix were often unavailable, that dressing changes were sometimes not done when scheduled, and that some nurses still checked off treatments as completed per order despite not having the correct supplies. CNAs reported dressings with old dates, unraveling, and drainage seeping through, and nurses documented worsening bilateral lower extremity redness, bleeding, purulent and greenish drainage, increased pain, and extensive weeping through dressings. The resident experienced episodes of dizziness, hypotension, and shortness of breath, was repeatedly sent to the hospital, and was ultimately diagnosed with septic shock secondary to bilateral leg wound infection and cellulitis due to pseudomonas and MRSA, with hospital records and the death certificate listing septic shock and skin and soft tissue infections as causes of death.

A second resident with congestive heart failure was also cited in the deficiency for failure to complete ordered lab work and administer medications as ordered, resulting in worsening CHF, respiratory failure, hospitalization, and subsequent death, but the detailed narrative in the report focuses on the first resident’s course. The surveyors determined that the facility failed to follow physician orders for antibiotics and wound care, failed to ensure availability and administration of ordered medications and supplies, and failed to adequately monitor and respond to the resident’s declining condition. These failures led to worsening infection of bilateral lower extremity venous wounds, development of sepsis, and the resident’s death, and contributed to an Immediate Jeopardy determination for failure to provide treatment and care according to orders, resident preferences, and goals for two of three residents reviewed for death.