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Based on record review, interviews and facility policy review, the facility failed to provide an antibiotic treatment as ordered by provider, failing to provide a safe therapeutic treatment, resulting in Patient not receiving antibiotics for the duration prescribed by provider for 1 of 3 patients sampled (Patient#1).

The findings include:

On 9/29/25, a review of Patient #1's medical record was conducted.
Patient #1 was a 62 years-old who was admitted to facility on 8/30/25 and expired on 9/7/25 at facility. Patient #1 presented to Emergency Department via transfer from North Okaloosa Medical Center (NOMC) on 8/30/25. Patient #1 had a primary diagnosis that included pneumonia.

Emergency Department (ED) triage documentation dated 8/30/25 at 9:25 PM indicated Patient #1 had received 1 Gram Cefepime (a medication used to treat bacterial infections) at NOMC.
ED documentation signed on 8/30/25 at 11:05 per Staff C, Medical Doctor (MD) indicated an order for Cefepime 1 g every 6 hours once with a stop date of 8/30/25 at 10:32 PM. Staff C, MD's documentation indicated Patient #1 went to outside hospital where he was noted to have pancytopenia (a blood disorder that occurs when the body does not produce enough of all three types of blood cells: red, white and platelets, cause by bone marrow issues) and pneumonia. Staff C, MD indicated Patient#1 was started on antibiotics. He further stated Patient#1's antibiotics were redosed here (ED).

Patient #1 was admitted as inpatient on 8/30/25 at 11:16 PM.

Documentation dated 8/31/25 at 1:21 AM per Staff B, MD was reviewed. Staff B, MD stated Acute left lower lung pneumonia, possible community-acquired pneumonia. Documentation added Patient #1 was Immunocompromised patient with pancytopenia, Shortness of breath, Productive cough. Plan stated: The patient will be admitted to medicine, telemetry unit as inpatient and will require at least 2 midnight for inpatient treatment. Documentation stated Cefepime was initiated and will be continued. Staff B, MD's documentation further revealed Patient#1's respiratory sounds were coarse bilaterally, and plan to administer cefepime 1 g IV every 6 hours. There was no duration indicated in the documentation.
Further review of Patient #1's medical record revealed Staff C, MD ordered Cefepime 2 G Intravenously every 8 hours for 3 days on 8/30/25 at 10:02 PM. This order was changed on 8/30/25 at 10:12 PM by Staff D, Registered Pharmacist (RPH) to 1 G every 6 hours with the same ordered duration of 3 days. On 8/30/25 at 10:46 PM, Staff B, MD entered and signed an order for Cefepime 2 G IV every 8 hours for 10 days, with a stop date on 9/9/25. On 8/30/25 at 10:47 PM, Staff D, RPh voided Staff B, MD's order.

A review of Patient #1's Medication Administration Record (MAR) was conducted. Patient #1 received Cefepime 1 G on 8/30/25 at 2214, on 8/31/25 at 556 AM, 1114 AM, 1606 PM and 1150 PM, on 9/1/25 at 551 AM, 1131 AM and 520 PM, and on 9/2/25 at 4:44 AM, 3:07 PM and 8:19 PM. Patient #1 did not receive any other doses of antibiotics until 9/7/25 at 1:02 AM which he received last dose. Patient #1 expired on 9/7/25 at 11:23 AM.

A review of Physician's progress notes was conducted. On 8/30/25, 8/31/25, 9/1/25 and 9/2/25 Staff F, MD stated plan to continue Cefepime. On 9/3/25, 9/4/25, 9/5/25 and 9/6/25, Staff E, Doctor of Osteopathic Medicine (DO) stated to plan to continue Cefepime.


On 9/29/25 at 11:11 AM an interview was conducted with Staff A, Risk Manager (RM). She stated facility was still investigating and had identified multiple deviations during Patient #1's stay; she added, there had been a Swish Cheese effect. She explained ED physician placed antibiotic for a duration for 3 days and later Hospitalist placed duration for 10 days. Pharmacist saw both orders. He changed ER doctor's orders and renally changed the dose, but it was timed for 3 days. Pharmacy admitted got distracted and did not change the ED order to 10 days after discontinuing order from hospitalist. She further stated that nurses had a part of verifying Patient #1 was not receiving antibiotics with a diagnosis of pneumonia.

On 9/29/25 at 12:53PM an interview was conducted with Staff G, RPh. She was asked to explain process of medication reconciliation. She explained that when orders from ED and floor differed, protocol was to reach out to provider and obtain approval to reject the order.

On 9/30/25 at 9:15 AM, an interview was conducted with Staff A, RM. She was asked to explain process of providers ensuring their plan of care (POC) and orders are being implemented. Surveyor then requested Policy and Procedures related to POC implementation. RM stated Hospital did not have a process in place. She further stated providers did not go back and looked at the orders.

On 9/30/25 at 9:30 AM, an interview was conducted with Staff H, Director of Nursing (DON) and Registered Nurse (RN). She was asked to explain the process of physician's orders flowing into the MAR. She explained physician's orders were seen in the MAR but until they were approved and verified by Pharmacy, the digital system would not allow to be administered. She was then asked to explain the process of medication reconciliation. She stated the nurses will verify the list of medications upon admission; the provider will then review the list and will determine which medications that were prescribed will go to Pharmacy for review. She further stated it was expected that nurses review provider's progress notes.

On 9/30/25 at 9:49 AM, an interview was conducted with Staff, I, Pharmacy Manager. He stated when duplicate orders for antibiotics occur (such as with this Cefepime), it was protocol to continue the most recent or current order. In this case, the Cefepime order duration of 10 days should have been continued, and the order for 3 day duration should have been discontinued based on the timing of the orders. If order clarification was needed, the ordering provider should be contacted. Unfortunately, he added, the most recent order was discontinued.

A review of facility Policy and Procedure Medication Management: Access to Information and Order Review, dated 8/2025, was conducted. Policy stated the clarification or verification of unusual medication orders or methods of administration, or contraindicated drugs require that the physician be contacted by a pharmacist. The Pharmacist will document all medication order clarifications. The Pharmacist checks for: a physician staff privileges b. therapeutic appropriateness of a patient's medication regimes c. completeness of medication order d. duplicate orders e. therapeutic duplicates f. contraindications g. potential allergies or sensitivities h. drug and food interactions j. appropriate medications, dose, frequency, and route of administration. Indication for medication order k. current possible impact of the medication as related to laboratory values. Any concerns, questions, or issues will be clarified with the prescriber before dispensing occurs with the exception of providing a one time dose for emergency situations.

A review of facility Policy and Procedure Transcribing and Administering Medications revised 6/2025 was conducted. Policy stated when a medication order is received by pharmacy, pharmacy will verify the order. It is the responsibility of the licensed caregiver to verify all medication orders against the prescriber's orders and confirm the orders. Orders should not be signed off in the patient record or confirmed in the electronic record unless they have been appropriately reconciled. When an order to discontinue a medication is received by pharmacy, the discontinue order will be denoted in the electronic record and it is the responsibility of the licensed caregiver to verify and confirm this order.