F0684

E

Failure to Follow Physician Orders for Narcotic Discontinuation and Timely Antibiotic Initiation

Biloxi, Mississippi Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide care and services in accordance with physician orders and professional nursing standards for two residents. For Resident #2, physician orders dated 12/17/25 directed initiation of Oxycodone-Acetaminophen 5-325 mg every six hours and discontinuation of Hydrocodone-Acetaminophen 10/325 mg once the new medication became available. Pharmacy records showed the Oxycodone-Acetaminophen was delivered on 12/26/25 at 8:00 AM. However, the Order Summary Report still listed both narcotic medications as active, and the December 2025 MAR documented administration of both Oxycodone-Acetaminophen 5-325 mg and Hydrocodone-Acetaminophen 10-325 mg from 12/26/25 through 12/29/25. The Controlled Drug Receipt/Record/Disposition Form further confirmed that Hydrocodone/APAP 10/325 mg continued to be signed out and administered four times daily during this period, despite the discontinuation order.

Resident #2 had been admitted on 6/4/25 with diagnoses including intervertebral disc degeneration of the lumbar region and had a BIMS score of 12 on the 2/5/26 MDS, indicating moderately impaired cognition. During interview, the DON confirmed that the Hydrocodone-Acetaminophen should have been discontinued when the Oxycodone-Acetaminophen became available on 12/26/25 and that nursing staff did not discontinue the medication as directed. RN #2 stated she administered both narcotic medications because both appeared as active on the MAR, did not question the duplicate opioid orders, did not verify whether Hydrocodone-Acetaminophen had been discontinued, and did not notify supervisory staff or pharmacy about the duplicate narcotic therapy.

For Resident #1, the deficiency centers on a delay in implementing a newly ordered antibiotic following return from the hospital. Progress notes showed the resident was transferred to a local hospital on 12/24/25 for non-reactive pupils, unequal pupil size, and feeling hot to the touch, and returned later that day on medication for a UTI. The hospital After Visit Summary dated 12/24/25 indicated a diagnosis of UTI and a new order to start nitrofurantoin (Macrobid). The facility’s Order Summary Report reflected a physician order for Macrobid 100 mg via PEG tube twice daily for UTI, but with an initial start date entered as 12/30/29 and later clarified to a 10-day course starting 12/30/25. The MAR showed that Macrobid was not administered until 12/29/25, resulting in a five-day delay from the time the order was received on 12/24/25. Resident #1 had been admitted on 10/22/24 with diagnoses including anoxic brain damage, and the 1/22/26 MDS documented the resident as comatose and in a persistent vegetative state with no discernible consciousness.