State Findings:
Based on record review, staff interviews and physician interviews, the facility neglected to (1) administer intravenous (IV) antibiotics to treat a stage IV sacral pressure sore for 12 days. This occurred for 1 of 3 residents (Resident #1) reviewed for intravenous therapy. This caused Resident #1 to be readmitted to the hospital with [CONDITION(S)] and bacteremia resulting in a second surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 passed away while in the hospital.
During a telephone interview with the Infectious Disease nurse practitioner (NP) on [DATE] at 11:26am, the NP discussed her follow up with Resident #1 on [DATE] was initiated by her due to the last date of the intravenous antibiotic was [DATE]. She discussed Resident #1 had developed an infection in the bone of her sacrum and was septic. She stated the sacral wound appeared significantly worse then when the resident was discharged from the hospital on [DATE]. She described the wound to have slough that was gray and no viable tissue covering the wound bed. The NP explained the resident had [CONDITION(S)] and bacteremia prior to the discharge on [DATE] but upon discharge the bacteremia had been cleared but the resident still required the intravenous antibiotic until [DATE] due to the [CONDITION(S)] and to prevent the bacteremia from returning. She attributed the deterioration of the wound and the resident being septic to not having the antibiotics for 12 days. The NP discussed sending the resident back to the hospital from her office on [DATE] where Resident #1 underwent surgery to debride the wound and perform a bone biopsy. She stated Resident #1 died on [DATE] with contributing factors of [CONDITION(S)] and untreated bacteremia.
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