F0760

G

Failure to Administer Ordered Antibiotic and Notify Physician of Missed Doses

Oconto, Wisconsin Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered antibiotic was not administered as prescribed. The resident, who was cognitively intact and responsible for their own healthcare decisions, had a history of left cheek cellulitis. On 12/15/25, nursing documentation described a 4–5 cm swollen, hard, red, warm, and painful area on the resident’s left upper cheek, with a small open center and increasing size and pain over at least three days. The nurse noted there were no prior requests to the physician for advisement, and the resident ultimately requested transfer to the ER that evening. The hospital diagnosed facial cellulitis and prescribed clindamycin 300 mg by mouth three times daily starting 12/16/25.

Upon return to the facility, the clindamycin order was not carried out as written due to medication unavailability from the pharmacy. The Medication Administration Record showed that three doses on 12/16/25 and two doses on 12/17/25 were not administered, with the first documented dose given on the PM shift of 12/17/25. The facility did not notify the physician about the missed doses. During this period, the resident’s cellulitis became more painful, leading the resident to request hospital transfer again on 12/17/25 and then again on 12/20/25. Subsequent hospital records documented a MRSA left cheek abscess with preseptal cellulitis requiring irrigation, debridement, wound packing, IV vancomycin, and continued wound care and oral antibiotics after discharge. The DON confirmed that clindamycin was not available in contingency stock, the pharmacy did not deliver it timely, and that the resident missed a total of five doses between 12/16/25 and 12/17/25.