VILLA HILLS, KY - A December inspection at Madonna Manor revealed serious medication administration failures that resulted in a resident being hospitalized with life-threatening sepsis after nursing staff repeatedly failed to administer prescribed antibiotics on time.
Critical Antibiotic Administration Failures
Federal inspectors identified a pattern of missed and delayed antibiotic doses for a cognitively intact resident admitted on November 26, 2024, for treatment of post-surgical infections. The resident had been prescribed two critical antibiotics: cefepime (2 grams intravenously twice daily at 9:00 AM and 9:00 PM) and metronidazole (500 milligrams orally every eight hours).
According to medication administration records, nursing staff failed to provide three complete doses of the IV antibiotic cefepime on November 26, November 27, and November 29. Additionally, staff administered doses outside the facility's own 60-minute window policy on four separate occasions, with delays ranging from 30 minutes to over two and a half hours. The oral antibiotic metronidazole was also missed on multiple occasions during the resident's stay.
On December 1, 2024, family members visiting at 11:10 AM discovered the resident unresponsive, feverish, sweating, and exhibiting seizure-like activity. The licensed practical nurse on duty acknowledged she had not yet seen the resident that morning or administered the 9:00 AM antibiotic dose. Emergency medical services transported the resident to the hospital, where physicians documented the resident presented in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response.
Medical Significance of Timely Antibiotic Administration
Consistent, timely administration of antibiotics represents a cornerstone of infection treatment. When antibiotics are given irregularly or doses are missed, bacterial populations can recover between doses, potentially developing resistance to the medication. This inconsistency allows infections to progress rather than resolve.
For serious infections requiring intravenous antibiotics, maintaining therapeutic drug levels in the bloodstream is essential. Each missed or significantly delayed dose creates gaps in coverage, giving bacteria opportunities to multiply. The combination therapy prescribed—cefepime and metronidazole—was designed to provide broad-spectrum coverage against the resident's post-surgical infections. When either component is administered inconsistently, the treatment regimen's effectiveness diminishes substantially.
The emergency department physician's assessment documented that the resident had "a high probability of imminent or life-threatening deterioration" requiring immediate intervention. The resident required admission to the critical care unit for several weeks and an additional 10 weeks of intravenous antibiotic therapy following hospital discharge—a significantly extended treatment course likely necessitated by the progression of inadequately treated infection.
Infection Control Lapses Compound Patient Safety Concerns
Inspectors documented additional infection prevention failures that placed residents at risk. Staff members were observed entering a contact isolation room without wearing required personal protective equipment on multiple occasions. One instance involved the facility's advanced practice registered nurse sitting on an isolated resident's unmade bed without gloves or gown while visiting with the patient.
Contact precautions exist specifically to prevent transmission of multidrug-resistant organisms and other communicable infections. The resident under isolation had documented history of such organisms and an active infection. Failure to use barriers creates direct pathways for pathogen transmission to staff members, who can then spread organisms to other residents throughout the facility.
Inspectors also observed improper handling of contaminated medical equipment. A licensed practical nurse carried a blood glucose meter contaminated with a resident's blood across common areas without gloves, then placed it directly on the medication cart without using a protective barrier. When observed cleaning the device on a subsequent occasion, the nurse wiped it for only 10 seconds—far short of the manufacturer's required one-minute contact time for proper disinfection.
Shared medical equipment requires scrupulous cleaning and disinfection between uses according to Environmental Protection Agency-registered protocols. Blood glucose meters contact residents' blood and can harbor bloodborne pathogens including hepatitis viruses and HIV. Inadequate cleaning creates infection transmission risks for subsequent patients.
Additional Issues Identified
Inspectors documented unsecured medications in an unlocked pharmacy delivery tote left unattended in a hallway. The container held intravenous antibiotics, saline solutions, anticoagulant injections, and respiratory medications accessible to anyone passing through the area. Facility policy required immediate secure storage of all medication deliveries.
The interim director of nursing acknowledged that while unit managers were responsible for auditing medication administration on their units, the facility maintained no formal documentation of such audits. This absence of systematic oversight likely contributed to the pattern of medication errors going undetected until the resident's emergency hospitalization.
Regulatory Response and Facility Actions
Federal inspectors cited the facility for immediate jeopardy to resident health or safety—the most serious category of violation—based on the medication administration failures. The facility submitted a removal action plan on January 2, 2025, outlining comprehensive corrective measures including daily medication audits, staff re-education on administration protocols, quiz assessments for all nursing personnel, and weekly reporting to the facility's quality assurance committee.
The resident who experienced the medication failures was discharged from Madonna Manor on December 1, 2024, following the emergency hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madonna Manor from 2025-01-03 including all violations, facility responses, and corrective action plans.
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