Failure to Notify Physician of Multiple Missed Antibiotic Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when a resident missed multiple ordered doses of an antibiotic. The resident was admitted with diagnoses including chronic osteomyelitis and diabetes and had a physician’s order dated 2/13/26 for doxycycline 100 mg by mouth twice daily indefinitely for chronic osteomyelitis. Review of the March 2026 MAR showed that on 3/9/26, both the lunch and evening doses were documented as not administered due to the medication being unavailable, with no corresponding documentation in the nursing progress notes that the physician was notified. On 3/10/26, the lunch dose was again documented as not administered because the medication was unavailable, and the evening dose was not given while staff documented they were waiting for pharmacy delivery, with no evidence of physician notification. Further review showed that on 3/11/26, both the lunch and evening doses were not administered due to the medication being unavailable or awaiting pharmacy refill, and on 3/12/26, both the lunch and evening doses were also not administered because the medication was unavailable. In total, eight doses of doxycycline were missed without physician notification. Interviews with multiple nurses confirmed they did not inform the physician when the antibiotic was unavailable and not administered, with some nurses stating they did not think it was necessary or did not realize notification was required. The DON stated she expected medications to be administered as ordered and that staff should notify the provider when a medication is not available. The physician reported being unaware that the resident had missed eight doses of the prescribed antibiotic and stated that medications should be available and administered as ordered, and that the provider should be notified if a medication is not available.
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