Failure to Obtain and Administer Prescribed Antibiotic for Active Infection
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer a newly prescribed antibiotic for a resident with active right ankle and foot osteomyelitis and cellulitis of the lower right limb. The resident was admitted with these diagnoses and later seen by podiatry, which prescribed doxycycline on 10/09/2025. According to a PA progress note dated 10/13/2025, the prescription was sent to an out-of-facility pharmacy and was not obtained or initiated by the facility. The PA documented that nursing staff were aware of the prescription and had informed the resident that it had been sent to an outside pharmacy. The PA also documented a discussion with the resident about the need to obtain the medication and that it could be delivered later that day or the following day. Record review of the October 2025 MAR showed the resident did not receive doxycycline from 10/09/2025 through 10/14/2025. The Discharge Transition Plan dated 10/14/2025 did not list doxycycline on the resident’s medication list, and the resident was discharged without documented access to the prescribed antibiotic. In an interview, the resident reported that her foot remained swollen with pus pockets and severe pain and stated she had informed nursing staff that she needed the prescribed antibiotic but did not receive it before discharge. In a subsequent interview, the DON confirmed the resident did not receive doxycycline during this period because the facility never ordered the medication from the out-of-facility pharmacy, despite being aware of the antibiotic order.
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