F0755

D

Failure to Accurately Administer and Document Antibiotic and Steroid Therapy

Buffalo, Missouri Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident with COPD, nontraumatic intracerebral hemorrhage, and kidney cancer. The resident had moderate cognitive impairment, shortness of breath with exertion, at rest, and when lying flat, and was receiving oxygen therapy. On one occasion, the resident was found with an oxygen saturation of 78% on six liters via nasal cannula, with bilateral wheezing and rhonchi and diminished lung sounds at the bases. Staff documented that the resident was on prednisone until a specified date and had completed a course of cefdinir for pneumonia, and the physician was notified for further recommendations.

Subsequent physician documentation showed that, due to non-resolving pneumonia, the resident was to continue cefdinir 300 mg PO BID for seven days and start prednisone 40 mg PO daily for five days, then decrease by 5 mg every five days until discontinued. The February Physician Order Sheet reflected an order for cefdinir 300 mg PO BID for seven days, and prednisone 40 mg PO daily for five days followed by prednisone 35 mg PO daily for five days. However, the February MAR showed cefdinir documented as administered twice daily for ten days, three days longer than ordered, and staff progress notes later documented that cefdinir was not available on two of those days. The MAR also showed no documentation of prednisone administration for the ordered periods, with only a single prednisone dose documented on a later date.

Observation of the medication storage revealed an unopened package of prednisone 35 mg, ordered once daily for five days, and a cefdinir medication card dated earlier in the month with three of fourteen capsules remaining, despite MAR documentation indicating administration beyond the seven-day order. Interviews with the Medical Director confirmed that all medications should be administered and documented as prescribed, and that he would presume medications were not given if not documented. Multiple CMTs and LPNs stated that medications should be administered as ordered, that blanks on the MAR indicate medications were not administered, and that unavailability or refusals should be documented on the MAR and in progress notes. Staff also reported issues with medication availability related to a pharmacy change. The DON and Administrator both stated that medications should be administered as prescribed, that there should be no blanks on the MAR, and that medications should not remain on the MAR past the stop date, but they were unaware of why cefdinir was documented past the stop date, why doses remained, or why prednisone doses were not documented or administered as ordered.