Federal inspectors found Mallard Bay Nursing and Rehab failed to revise care plans for a resident who underwent multiple rounds of IV antibiotic therapy from June through October 2025. The resident, who has systemic lupus erythematosus and rheumatoid arthritis, was readmitted to the facility in May 2025.
The treatment regimen was extensive. The resident received Vancomycin through a peripherally inserted central catheter, known as a PICC line, for several days from June 2025 to October 2025. Staff administered Daptomycin via the same PICC line from August through September 2025. In October, the resident also received Amoxicillin-Pot Clavulanate by mouth.
None of these treatments appeared in the resident's care plan.
When inspectors reviewed the clinical record on October 20, they found no care plan interventions addressing antibiotic therapy or PICC line care during the months-long treatment period. PICC lines require specialized nursing care to prevent infections and complications, including regular flushing, dressing changes, and monitoring for signs of infection or displacement.
Unit Manager LPN#3 confirmed the missing care plan updates during an interview the following morning. She acknowledged that facility practice required updating resident care plans to match their current condition and clinical treatments.
She offered no explanation for why the resident's care plan wasn't updated.
The facility's failure violated federal requirements that nursing homes develop complete care plans within seven days of comprehensive assessments and ensure they are prepared, reviewed, and revised by a team of health professionals. Care plans serve as roadmaps for staff, detailing specific interventions needed to meet each resident's medical needs.
For residents receiving IV antibiotics, care plans typically include monitoring protocols for drug side effects, infection prevention measures, and specific procedures for maintaining central line catheters. Without these written protocols, different staff members may provide inconsistent care or miss critical monitoring requirements.
The Director of Nursing was informed of the inspection findings on October 21.
The violation occurred during a complaint survey, suggesting someone reported concerns about care at the facility. Federal inspectors classified the deficiency as causing minimal harm or potential for actual harm, affecting few residents.
Systemic lupus erythematosus is an autoimmune disease that can affect multiple organ systems and often requires immunosuppressive medications, making patients more susceptible to infections. Rheumatoid arthritis, another autoimmune condition, can also increase infection risk, particularly when treated with certain medications that suppress the immune system.
The combination of these conditions likely contributed to the resident's need for multiple courses of powerful intravenous antibiotics over several months. Vancomycin is typically reserved for serious infections, including those caused by methicillin-resistant Staphylococcus aureus (MRSA). Daptomycin treats severe skin and bloodstream infections.
PICC lines, while useful for delivering long-term IV medications, carry significant risks including bloodstream infections, blood clots, and catheter displacement. These complications can be life-threatening, making proper care protocols essential.
The inspection report doesn't indicate whether the resident experienced any complications from the missing care plan protocols. However, the failure to document and standardize care procedures created potential risks that could have resulted in medication errors, missed monitoring, or improper catheter care.
Federal regulations require nursing homes to maintain current, comprehensive care plans that reflect residents' changing medical needs. These plans must be developed by interdisciplinary teams including nurses, physicians, and other healthcare professionals, then regularly reviewed and updated as conditions change.
The resident's complex medical history and months-long antibiotic treatment clearly warranted updated care planning. The facility's acknowledgment that updating care plans was standard practice, combined with the unit manager's inability to explain the oversight, suggests a breakdown in the facility's care planning process.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mallard Bay Nursing and Rehab from 2025-10-22 including all violations, facility responses, and corrective action plans.
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