IDPH has cited and fined Alden Estates Courts of Huntley nursing home after a resident there had to undergo surgery to replace an artificial knee after developing an infection brought on by the failure of the nursing home to obtain and give antibiotics that had been ordered for the resident.
The resident at issue had a history of chronic discitis bacteremia, which mean that her low back was colonized with infectious organisms In this case it was staph bacteria. To combat this and prevent the bacteria from spreading to other parts of her body, the resident had been permanently placed on an antibiotic called doxycycline prophylactically, meaning that she was to receive the mediation on an ongoing basis to keep her from getting critically ill with sepsis. Once the body is colonized with infection-causing bacteria, they can cause infection in other parts of the body. Implants such as artificial joints, stents, and pacemakers are often places where infection results.
When the resident was admitted to the nursing home from the hospital with orders on the discharge papers to receive an antibiotic doxycycline, 100 mg twice per day. However, when the resident was admitted to the nursing home, the order was never transcribed onto the physician order sheet, and as a result, the medication was never ordered from the pharmacy. With the orders never transcribed onto the order sheet and the medication never obtained, the resident did not receive any of the antibiotic that was ordered for her for the first 13 days of her admission to the nursing home.
After missing the first 13 doses, the resident suffered an episode of chest pain and was admitted to the hospital for a total of 13 days. When she was discharged from the hospital, she again had orders for doxycycline, 100 mg twice per day. Once again, the order was never entered into the physician order sheet and the medication was never ordered.
The net effect of this nursing home medication error is that the resident did not receive a total of 52 doses of the medication that was ordered to suppress the bacteria and prevent her from suffering a serious infection.
Due to not receiving the medication that had been ordered for her, the resident developed an infection and was sent to the hospital in a critically ill condition. She was suffering from septic shock and had an infection of her artificial knee. Due to the infection of the knee prosthesis, she had undergo surgery to remove the prosthesis and have a new one implanted. The orthopaedic surgeon attributed the infection to the bacteria which were intended to be controlled by the antibiotic which the resident did not receive.
Assuring continuity of care is a critical part of helping nursing home residents maintain their health and well-being. Nursing home resident are almost always admitted suffering from some condition of ill-being whether it is acute, as may the case with patients admitted for short-term rehabilitation, or may suffer from long-term chronic medical conditions, as was the case here. The common thread between them is that these conditions are being managed by a physician who is relying upon the nursing home home staff to implement the care that they have ordered. When they do not, catastrophe can result.
Nursing homes are businesses, and well-run businesses have systems in place to carry out their basic functions. Admitting residents to the nursing home and assuring continuity of care is one of those basic functions. Here there was clearly a problem with the system that the nursing home was operating under, as the antibiotic ordered for this resident was not given after two separate admissions. The fact that this was a common thread between the two admissions speaks to a larger problem than a simple breakdown of the system due to human error. Once could be a mistake, twice could be a larger issue.
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