Failure to Obtain and Administer Ordered Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed pharmaceutical services by not obtaining and administering doxycycline 100 mg twice daily as ordered for a resident with chronic osteomyelitis and diabetes. A physician order dated 2/13/26 directed that the resident receive doxycycline 100 mg by mouth twice per day indefinitely for chronic osteomyelitis. Review of the March 2026 MAR showed that eight consecutive doses of doxycycline were not administered on 3/9/26, 3/10/26, 3/11/26, and 3/12/26, with nurses documenting that the medication was unavailable, awaiting pharmacy delivery, or awaiting pharmacy refill. The physician later stated she was unaware that eight doses had been missed and indicated that medications should be available and administered as ordered. On 3/9/26, the nurse assigned from 7:00 AM to 7:00 PM documented that the lunch dose was not given because the medication was unavailable in the resident’s medication cabinet and acknowledged she did not check the automated medication dispensing machine or contact the pharmacy or local backup pharmacy. Another nurse documented the evening dose on 3/9/26 as unavailable and not administered. On 3/10/26, one nurse documented the lunch dose as unavailable and not administered, and another nurse documented the evening dose as waiting for pharmacy delivery and not administered. On 3/11/26, the day nurse documented the lunch dose as unavailable and awaiting pharmacy refill, and reported that she did not check the automated dispensing machine or contact the pharmacy, assuming the medication would arrive later. On the nights of 3/11/26 and 3/12/26, the night nurse reported that the doxycycline was not in the resident’s medication cabinet and that, although she checked the automated dispensing machine, the correct dose was not available there. She acknowledged that she did not contact the pharmacy on 3/11/26 and, when she did call on 3/12/26, she did not request that the medication be sent through the backup system and did not report the discrepancy in dosing frequency between the pharmacy’s once-daily entry and the facility’s twice-daily order to the DON or physician. The DON stated she expected medications to be administered as ordered and that nurses should notify the pharmacy and use the automated dispensing machine and local backup pharmacy when medications were not available. The Pharmacy Manager reported that the pharmacy had systems for daily availability, including twice-daily deliveries and backup processes, and stated that if notified, the doxycycline would have been sent through the backup system; he also confirmed the pharmacy had entered the order as once daily instead of twice daily and acknowledged the potential risk for worsening of the infection due to the missed doses.
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