HOUSTON, TX – ASHFORD GARDENS

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (CR#1) of 12 residents reviewed for quality of care. The facility failed to ensure CR #1 antibiotic medication was ordered from the pharmacy, regardless of the price of the medication. CR #1 went without a critical antibiotic medication for 4 days, had a change of condition, and was admitted to the hospital intensive care unit with a [DIAGNOSES REDACTED]. On 1/15/2018, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 1/17/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 1 former resident requiring hospitalization and caused a decline in health and quality of life.

In a telephone interview on 1/10/19 at 12:05pm, CR #1’s family member said she felt like the facility refused to give the antibiotic medication. The family member stated whenever she asked about the medication, they always told her they had not received it yet. Family member said CR #1 was talking and moving around when she was admitted to the facility but on Thursday, 12/20/18, she started feeling sick, sleepy and coughing a lot. Family member said CR #1 had been in the ICU since she was discharged.

In an interview on 1/10/19 at 12:30pm, the DON said CR #1’s antibiotic medication was expensive. She said the pharmacy had it in stock. She said because the resident was on Medicare, the facility would have been responsible for the cost. She said she asked MD A on 12/19/18 if he would change the medication to something else, and he refused. She said this physician was difficult to work with. She said they asked the Medical Director if he could change the medication, and he did not want to get involved because he knew MD [NAME] She then asked the social worker to reach out to the manufacturer to get the medication at a lower cost. She said the family was involved and notified of the issues. She said because she had a nephrectomy (surgical removal of a kidney) so they had to be careful with the type of medication you give her. She said [MEDICATION NAME], the medication she requested MD A change her order to, was more careful on the system. She said usually, when a medication was too expensive, the physician would change the order. When asked what the risk was if she did not receive the antibiotic as ordered, she said the infection could come back.

In a telephone interview on 1/11/19 at 1:28pm, MD A said he had worked with CR #1 since (MONTH) (YEAR) during her stay at the hospital and the LTAC facility. He said she [MEDICAL CONDITION] 4 or 5 times during her stay. He said the infectious disease physician recommended the antibiotic medication because she did not respond to other [MEDICATION NAME] agents. He said the nursing facility agreed to order the antibiotics. He said the facility was supposed to call him to verify the admission orders [REDACTED]. He said he visited the facility on 12/19/18 and talked to the DON and Unit Manager about the resident’s antibiotic medication. He said they told him they had to get it from the pharmacy. He said he told them CR #1 needed them now because she had been on them since (MONTH) (YEAR). He said the next day the facility did not get the antibiotics and he was not notified. He said the next day, 12/21/18, he got a call from the nurse who stated the resident did not look good and they were transferring her to the hospital. He said he went to the facility to see her and said she looked severely septic, shaking, chills, shortness of breath. He said when she arrived to the ER, she was intubated and given antibiotics. He said the infection got worse and attributed her condition to the missed doses of the antibiotic. He said, It’s disheartening .totally negligent.