Failure to Provide Ordered Antibiotic Therapy Due to Cost and Procurement Issues
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when an ordered antibiotic for osteomyelitis was not provided as prescribed. The resident had multiple diagnoses including Parkinson's disease, a stage 4 sacral pressure ulcer, Alzheimer's disease, and dementia, and a CT scan showed findings consistent with osteomyelitis of the coccygeal segments. A wound physician documented that the CT scan of the stage 4 sacral pressure wound demonstrated osteomyelitis and recommended ciprofloxacin 500 mg twice daily for 42 days and linezolid 600 mg twice daily for 42 days. However, the physician’s orders reflected only linezolid 600 mg twice daily, and the medication administration record showed that, over a nine-day period, the resident received only 4 of 16 scheduled doses of linezolid. The resident’s daughter reported that the facility told her rules and regulations did not allow the family to bring in less expensive medications and that she had to contact the VA to obtain coverage for linezolid. She stated that the medication was started two days after it was prescribed and that this delay would have been longer if she had not intervened regarding VA coverage. Nursing staff later stated that linezolid had been discontinued, but the RN interviewed did not know who discontinued it or why, only that it appeared the facility did not have the medication. The DON and wound care nurse explained that the pharmacy identified linezolid as a high-cost medication, that only a few days’ worth of doses were initially supplied, and that they were attempting to secure coverage through prior authorization and the VA while continuing ciprofloxacin. The administrator stated that high-cost private pay medications are handled by informing families of the cost and that the facility must use its contracted pharmacy or the VA, not outside pharmacies. The wound physician emphasized that linezolid was important for treating the resident’s suspected osteomyelitis and that it was the only recommended oral antibiotic option, noting that IV alternatives would require RN availability. The DON later stated that the resident’s son/POA declined treatment after learning the cost of the medication and that they discussed holding the medication and possible IV alternatives with the wound physician, but no documentation of these conversations existed in the resident’s progress notes until several days after the issues arose. The facility’s medication administration policy required that all medications be administered as prescribed by the physician, which did not occur in this case, resulting in missed doses and interruption of the ordered antibiotic therapy.
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