IDPH has cited and fined Belleville Healthcare Center after the staff failed to order an antibiotic to treat a leg infection for over a week . . . and neglected to inform the resident’s doctor of the delay. The resident subsequently died of sepsis shock and bacteremia.
The resident in question suffered from multiple medical conditions including anemia, vitamin deficiency, and skin changes putting him at risk for complications.
When the resident developed swelling in his left leg, doctors ordered tests and an antibiotic, cefixime, to treat early signs of infection.
Critically, the nurse at the nursing home could not enter the prescription due to a possible drug allergy alert.
The nurse notified the wound care nurse of the issue but did not notify the doctor that the antibiotics were not started. Over the next week, the resident missed 10 doses of antibiotics. His leg continued deteriorating yet the doctor was not updated about the missed medication doses or worsening wound.
Approximately one week later the doctor had to reorder the same antibiotic prescription.
Approximately another six days passed until a wound doctor first evaluated the resident and found a severe infection requiring debridement surgery, stating “By the time I was notified of the resident’s wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight. His whole left leg was a big bag of pus. I had never seen anything like it . . . The facility should have been monitoring the resident more closely.”
Approximately two weeks after the appointment with the wound doctor the resident was admitted to the hospital for sepsis and shock. He tragically passed away from widespread infection four days later.
Timely intervention with antibiotics and proper communication with doctors may have prevented such a tragic death.
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