GLENWOOD, MN - A state health inspection revealed that Glenwood Village Care Center failed to properly monitor and document the prolonged use of prophylactic antibiotics for a resident with a complex medical history, raising concerns about the facility's medication management protocols and antibiotic stewardship practices.
Undocumented Prophylactic Antibiotic Treatment Discovered
The May 21, 2025 inspection uncovered that Resident 34, who had a history of recurring sepsis, urinary tract infections, urostomy, and previous bladder cancer treatment, was receiving prophylactic antibiotics without proper documentation, physician awareness, or clinical justification in the facility's records.
The consultant pharmacist told investigators that while notes about the medication were entered into the pharmacy's system, they were never transferred to the facility's system where physicians could access them. "It was important for the physician to have additional notes and justification to support the continued antibiotic usage," the consultant pharmacist stated during the investigation.
More concerning was the revelation that neither the facility's care manager nor the director of nursing knew the resident was taking the prophylactic antibiotic. The care manager admitted during the investigation that they "thought R34's primary provider ordered the medication due to another medication being stopped," demonstrating a fundamental breakdown in medication tracking and communication.
Medical Director Unaware of Treatment Plan
Perhaps most troubling was the discovery that the facility's medical director was completely unaware of the antibiotic regimen. During a phone interview on May 22, the medical director confirmed he "was not aware R34 was receiving a prophylaxis antibiotic" and acknowledged he was not the resident's primary provider. He speculated the medication was "probably on the medication due to R34's medical history" but had no documentation to support this assumption.
This lack of physician oversight represents a serious deviation from standard medical practice. Prophylactic antibiotics require careful monitoring and regular reassessment to determine if continued use is medically necessary. Without proper physician involvement, residents face increased risks of developing antibiotic-resistant infections, experiencing adverse drug reactions, and suffering from complications related to prolonged antibiotic exposure.
Critical Failures in Antibiotic Stewardship
The facility's own Antibiotic Stewardship Policy, revised February 21, 2025, clearly outlined requirements that were violated in this case. The policy mandated that antibiotics be prescribed for the correct indication, dose, and duration with appropriate documentation. It specifically required that prescribing practitioners maintain documentation of periodic reviews of antibiotic use.
Long-term prophylactic antibiotic use carries significant medical risks that require careful oversight. Extended antibiotic exposure can lead to the development of antibiotic-resistant organisms, making future infections more difficult to treat. Additionally, prolonged antibiotic use can disrupt the body's natural bacterial balance, potentially causing gastrointestinal complications, increased susceptibility to other infections, and allergic reactions that may develop over time.
For residents with complex medical histories like Resident 34, who had undergone bladder cancer treatment and had a urostomy, the stakes are particularly high. These individuals often have compromised immune systems and are more vulnerable to both infections and medication side effects. The absence of proper monitoring could mask important changes in the resident's condition or delay necessary adjustments to their treatment plan.
Industry Standards and Best Practices Ignored
According to established medical protocols, prophylactic antibiotic use should involve regular reassessment at defined intervals, typically every 30 to 90 days depending on the indication. Each continuation should be based on documented clinical need, with clear rationales recorded in the medical record. The prescribing physician should evaluate whether the benefits of continued prophylaxis outweigh the risks, considering factors such as the frequency of previous infections, the resident's overall health status, and any changes in their condition.
The facility should have implemented a systematic review process involving the prescribing physician, consultant pharmacist, and nursing staff. Monthly medication reviews should have flagged the long-term antibiotic use for physician evaluation. The consultant pharmacist's concerns should have been communicated directly to both the facility's nursing staff and the prescribing physician through the facility's documentation system, not just noted in the pharmacy's separate records.
Communication Breakdown Between Healthcare Providers
The investigation revealed a concerning pattern of fragmented communication between the various healthcare providers responsible for Resident 34's care. The consultant pharmacist noted that multiple pharmacists had served the facility over the previous six months, potentially contributing to the oversight. While the pharmacist indicated "the facility should have received a note to review this medication with the provider during last rounds," this critical communication never reached the appropriate medical staff.
The director of nursing's statement that "her expectations were all medication had proper diagnosis, duration and rationales with supporting documentation" highlighted the gap between facility policy and actual practice. This expectation represents the minimum standard for medication management in long-term care facilities, yet it was not met in this case.
Additional Issues Identified
The inspection also noted that the facility's medication monitoring system failed to identify the prolonged antibiotic use despite having an established antibiotic stewardship program. The facility's policy required providing feedback to prescribing practitioners on antibiotic use patterns and resistance patterns, but this system failed to function as designed. The breakdown in communication between the pharmacy system and the facility's medical records created a dangerous information gap that left the resident's antibiotic treatment essentially unmonitored for an extended period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenwood Village Care Center from 2025-05-21 including all violations, facility responses, and corrective action plans.
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