Antibiotic Delayed, Resident Dies

By Walter F. Roche Jr.

Health care workers at a Tennessee assisted living facility failed to administer a prescribed antibiotic to a resident for four days and she died days later with a massive infection, according to a report from the state Health Department.
The details of the 87-year old woman's illness and subsequent death were included in a 15-page report on Morningside of Paris, an 84 unit assisted living facility. As a result of the Nov. 6 inspection state Health Commissioner Lisa Piercey imposed a freeze on any new admissions to the facility.
Morningside officials did not dispute the state action and said they were working with health officials to correct any deficiencies
The inspection report also questions the handling of the resident, identified only as Resident 12, and her death certificate after she was found unresponsive on Oct. 22.
"Resident 12 was not pronounced deceased by a qualified individual," the report states, noting that the death certificate was not signed until a week after the patient's death, well beyond the 48-hour required limit.
Resident 12 was admitted to a secure unit in the facility on May 3, 2016 and had multiple conditions including schizophrenia, dementia and Alzheimer's disease, records showed.
A review of patient records showed the resident was seen on Oct. 11 for a possible eye infection. A sample collected on that date also showed she had escherichia coli in her urine, which the report noted can result in death if left untreated.
A prescription for an antibiotic was ordered, ampicillin two times a day, the report states. But her first dose of the antibiotic was not administered until 6 p.m. on Oct. 15, when a new prescription was issued by the family nurse practitioner overseeing the resident's care.
Subsequently, the records show, the facility staff learned that the original Oct. 11 prescription had been sent to the wrong address.
When state investigators questioned the nurse practitioner she said she was unaware the drugs had been sent to the wrong address.
The nurse practitioner did say that she had given the patient another antibiotic by injection, although the required documentation was not on file at the facility. The nurse told state surveyors that the documentation was on file at her location.
As for the death certificate, the report questions whether the physician who signed the document had ever even seen or treated the patient.
"There was no documentation Physician 1 had treated, assessed or examined Resident 12 at any time prior to the resident's death," the report states.
Though the death certificate lists sepsis as a contributing cause, it lists medullary failure as the cause of death. The nurse practitioner said she was not aware of the documented cause of death on the death certificate and was "not familiar with that term."
Morningside issued a response to the report stating," We are committed to maintaining a safe and comfortable community," adding that they were working with state health officials to correct and deficiencies.
"In the interim we continue to operate as usual providing outstanding care to facility residents," the statement concluded.