Federal inspectors found Hammond-Whiting Care Center failed to properly administer medications to Resident B, who had been diagnosed with osteomyelitis, paraplegia, anxiety, high blood pressure, muscle weakness, and ulcerative colitis.
The resident arrived at the facility on July 8 with a physician's order for alprazolam 1 milligram at bedtime for anxiety. Three days later, doctors ordered vancomycin 1.25 grams intravenously twice daily for a wound infection related to the bone condition.
But medication records show a pattern of missed doses. The antibiotic vancomycin wasn't signed out as given on July 9 for either the morning or evening dose, and again missed both doses on July 10. The anxiety medication alprazolam went unsigned on July 8, 9, 10, 11, 14, 15, 17, and 18.
The Assistant Director of Nursing admitted the problems started with incomplete hospital discharge paperwork. The facility received discharge documents but not the After Visit Summary that would have detailed medication orders.
"The vancomycin was not listed on the discharge paperwork," she told inspectors on September 15. She had called the hospital twice trying to get the summary sent over.
The next day, staff reached someone who promised to send wound treatment orders and fax the After Visit Summary. The fax never arrived.
"She understood she should have followed up," inspectors noted.
The resident herself raised concerns about the missing medication. She complained to staff that she was supposed to be on antibiotics, prompting them to finally contact her physician.
During interviews, the nursing director acknowledged multiple failures in the admission process. She had personally admitted the resident and should have verified antibiotic orders with the doctor, especially since the woman arrived with an osteomyelitis diagnosis but without the After Visit Summary.
"She understood this resulted in a delay in treatment and 4 missed doses of Vancomycin," the inspection report states.
The anxiety medication presented a different problem entirely. When the nursing director contacted the pharmacy in September, they said they were waiting on a prescription for the resident's alprazolam. The medication was never filled because no prescription had been sent.
She asked nursing staff why the resident didn't receive her anxiety medication. They had no answer.
Osteomyelitis is a bone and muscle infection that can become life-threatening without proper antibiotic treatment. Vancomycin is typically prescribed for serious infections that don't respond to other antibiotics.
The resident was cognitively intact according to her admission assessment, meaning she was fully aware of the medication delays and their potential consequences.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it affected the facility's ability to provide appropriate treatment according to physician orders and resident preferences.
The inspection was conducted as a complaint investigation in September, more than two months after the medication errors occurred. The facility's medication administration failures violated federal requirements for nursing homes to ensure residents receive proper pharmaceutical care.
Hammond-Whiting Care Center's problems highlight how administrative gaps can directly impact patient care. Missing hospital paperwork led to four days without critical antibiotics for a bone infection, while pharmacy communication failures left a resident without anxiety medication for over a week.
The nursing director's admission that she should have followed up on missing documentation underscores how preventable these medication errors were. A single phone call to verify orders could have prevented days of missed treatment for a resident battling a serious infection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hammond-whiting Care Center from 2025-09-16 including all violations, facility responses, and corrective action plans.