Resident 117 was supposed to receive Levofloxacin 750 mg daily from August 21 through August 26 to treat pneumonia diagnosed after a chest X-ray revealed infection in the left lower lobe of his lung. The 162-bed Wyant Woods Healthcare Center administered the antibiotic as ordered on August 20 and 21.
Then the medication ran out.
On August 22 and 23, nurses documented the antibiotic was "not available" but took no further action. Progress notes show staff knew the Levofloxacin was on order both days but made no record of contacting the prescribing physician about the interruption in treatment.
The resident has lived at the facility since November 2021 with multiple serious conditions including right-side paralysis from a stroke, epilepsy, brain dysfunction, and mood disorders. He requires substantial help with most daily activities but maintains normal cognitive function, scoring 13 out of 15 on a mental status assessment.
Registered Nurse 693 told federal inspectors she checked the facility's automated medication dispensing system but found it empty. She contacted the pharmacy requesting emergency delivery of the antibiotic, but it never arrived.
"They were supposed to have it drop shipped, but it never came," the nurse said during an October interview.
Corporate Nurse 800 confirmed the resident missed his prescribed antibiotic doses on both August 22 and 23 because "the medication was not available."
Neither nurse documented any attempt to reach the physician who had ordered the five-day antibiotic course specifically for pneumonia treatment.
The resident's medical history shows he has been under guardianship since 2015 due to his cognitive and physical impairments from the stroke. His care plan indicates he needs help with bathing, dressing below the waist, putting on shoes, and personal hygiene. He requires substantial assistance using the bathroom and getting dressed above the waist.
The missed antibiotic doses occurred during what should have been the middle of his treatment course. The physician had originally ordered the Levofloxacin on August 20 for a general infection, then reordered it the next day specifically targeting pneumonia after reviewing the chest X-ray results.
Federal inspectors discovered the medication error while investigating a complaint at the facility. The violation affects medication administration policies requiring staff to give drugs only as prescribed by physicians.
Facility policy from 2013 explicitly requires staff to "administer medications only as prescribed by the provider." The policy makes no mention of procedures when medications are unavailable from the pharmacy.
The inspection found that one out of four residents reviewed had experienced medication errors. Inspectors classified the violation as causing minimal harm or potential for actual harm.
The resident's treatment timeline shows the significance of the missed doses. His chest X-ray on August 18 revealed the lung infection. Two days later, his physician ordered the antibiotic treatment. By August 22, when the first dose was missed, the resident should have been receiving his second day of pneumonia-specific treatment.
Instead, he went 48 hours without the prescribed medication while nursing staff documented the problem but failed to alert the physician who could have prescribed an alternative antibiotic or arranged for emergency medication delivery.
The facility's medication administration records show nurses used a coding system to document the missed doses, marking them with the number nine and their initials. But progress notes reveal no follow-up actions beyond noting the medication remained on order.
During the October inspection, nursing staff confirmed the pharmacy failure but acknowledged they never contacted the prescribing physician to report the treatment interruption. The resident completed his antibiotic course once the medication became available, but the two-day gap in treatment occurred during the critical early phase of pneumonia therapy.
The case illustrates how pharmacy supply problems can compromise resident care when nursing staff fail to implement backup procedures. While the facility's automated dispensing system was empty and the pharmacy's emergency delivery failed, no one took the additional step of notifying the physician who prescribed the treatment.
Resident 117's pneumonia treatment was ultimately delayed by circumstances beyond his control, leaving him vulnerable to complications during a 48-hour period when his prescribed antibiotics sat unavailable in the facility's medication system.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wyant Woods Healthcare Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
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