Failure to Implement Antibiotic Stewardship Program
Summary
The facility failed to implement an Antibiotic Stewardship Program effectively, as evidenced by incomplete antibiotic usage audit tools and the unnecessary prescription of antibiotics for residents. The facility's policy on Antibiotic Stewardship, revised in October 2022, mandates the establishment of an antimicrobial stewardship team and the use of audit tools to track and evaluate antibiotic prescribing patterns. However, the Monthly Resident Infection and Antibiotic Stewardship Report tools for December 2023, January 2024, and February 2024 were found to be incomplete, with missing documentation on signs and symptoms of illness for numerous residents who were prescribed antibiotics. Specifically, 23 out of 25 residents in December, 16 out of 16 residents in January, and 11 out of 13 residents in February had no documented signs or symptoms of an illness, yet all were prescribed antibiotics. Resident #40, admitted in January 2024 with acute kidney failure and a urinary tract infection (UTI), was prescribed Ciprofloxacin for a questionable UTI. The urine culture results indicated contamination or colonization, suggesting no actual infection. Despite this, Resident #40 received the full course of antibiotics, and the February 2024 Monthly Resident Infection and Antibiotic Stewardship Report tool failed to include any information regarding this resident's UTI, antibiotic usage, or signs and symptoms of infection. The Infection Preventionist (IP) admitted that Resident #40 did not meet the McGeer Criteria for antibiotic use and that the physician should have been notified and the notification documented. Interviews with the Staff Development Coordinator (SDC), the IP, and the Director of Nursing (DON) revealed gaps in the facility's antibiotic tracking and reporting processes. The SDC, who was assisting the IP, acknowledged the incomplete report tools and the lack of surveillance for other potential illnesses. The IP, who was covering for the primary IP on leave, was unaware of how to complete the monthly infection reports and admitted to not following up with physicians within three days of antibiotic use. The DON confirmed that the antibiotic tracking books were monitored by the IP and that Resident #40 should have been included in the February 2024 report tool, with the physician notified of the continued antibiotic use, which did not happen.
Penalty
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The facility failed to implement an effective antibiotic stewardship program, resulting in multiple residents receiving antibiotics without timely or accurate application of McGeer criteria and incomplete infection surveillance documentation. When the Infection Preventionist (an LPN) was off duty, no one reviewed new antibiotic orders, so residents were started on systemic antibiotics before determining if infection criteria were met or before contacting a physician about non-qualifying cases. One resident with a toe wound was documented as meeting McGeer criteria for a wound infection even though only redness and swelling were recorded, contrary to the requirement for four signs or symptoms. Another resident with a breast abscess was started on Bactrim and topical mupirocin without an infection report form or log entry until several days later, and the form later contained an erroneous fever entry that conflicted with the infection log. A third resident on Levaquin for pneumonia initially lacked a completed McGeer form and log entry, and only later was documented as meeting all required pneumonia criteria, with the LPN acknowledging the review was not done in a timely manner despite an existing antibiotic stewardship policy requiring such review.
The facility failed to implement its antibiotic stewardship program for two residents who were documented in the infection control log as having in-house UTIs and were treated with antibiotics, despite no recorded UTI signs or symptoms in their medical records. For both residents, who had intact cognition and were dependent for ADLs, the infection control log indicated that McGeer’s criteria were met, yet there was no supporting clinical documentation or completed McGeer’s assessments. The DON confirmed the absence of documented UTI symptoms and assessments, even though the facility’s antibiotic stewardship policy required the infection control nurse or designee to review antibiotic utilization to ensure appropriate prescribing and use.
The facility failed to follow its antibiotic stewardship policy and McGeer’s criteria when managing antibiotics for three residents treated for suspected UTIs. One resident with bladder cancer and a catheter continued on Cefuroxime even though she had no documented UTI symptoms, her urine culture showed pseudomonas aeruginosa below McGeer’s CFU threshold, and Cefuroxime was not listed on the sensitivity report; the stewardship form also lacked clear physician attribution and symptom documentation. A second resident with diabetes and CKD received Keflex for a UTI despite only a single mildly elevated temperature, no urinary symptoms, and a culture whose sensitivity report did not include Keflex, with no evidence the prescriber reviewed this mismatch; the DON later acknowledged the stewardship form incorrectly stated repeated fevers and McGeer’s criteria being met. A third resident with diabetes and hypertension was given a full course of Macrobid for a UTI, but no stewardship evaluation was completed and there was no documented physician follow-up after a urine culture showed mixed organisms below McGeer’s CFU threshold, contrary to policy requiring culture results to guide starting, continuing, modifying, or discontinuing antibiotics.
A resident with dementia and chronic kidney disease returned from the hospital with a UTI diagnosis and was prescribed Keflex, despite urine culture results showing the infection was caused by Enterobacter Cloacae, which was not sensitive to that antibiotic. The acting IP identified the mismatch but incorrectly documented the organism and did not ensure the antibiotic was changed, resulting in the resident receiving a full course of an ineffective antibiotic, in violation of the facility's antibiotic stewardship policy.
A resident with multiple infections and a complex medical history received several courses of antibiotics without the required antibiotic time out assessments being performed. Staff confirmed that these assessments, which are part of the facility's antibiotic stewardship program, were not completed as outlined in facility policy.
The facility did not monitor or address recurring infection patterns, including multiple cases of UTIs, skin, fungal, osteomyelitis, and respiratory infections across several units. Despite documentation of these trends, there was no evidence of staff education, monitoring, or auditing to prevent further spread, as confirmed by an RN interview.
Failure to Implement Effective Antibiotic Stewardship and McGeer Criteria Review
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective antibiotic stewardship program that ensured appropriate antibiotic use and timely application of McGeer criteria. Surveyors found that the Infection Preventionist (an LPN) was off work over a weekend, and during that time multiple residents were started on antibiotics without any determination of whether they met McGeer criteria. The Director of Nursing and the Infection Preventionist acknowledged that when the Infection Preventionist is off, no one performs her infection control duties, including reviewing new antibiotic orders against McGeer criteria. As a result, residents were receiving antibiotics before any assessment of criteria, and the facility was administering antibiotics prior to notifying the physician if criteria were not met or obtaining a rationale for antibiotic use without meeting criteria. One resident had a history of multiple chronic conditions including acute respiratory failure with hypoxia, chronic pain syndrome, hypertension, hyperlipidemia, morbid obesity, syncope, chronic congestive heart failure, depression, GERD, insomnia, osteoarthritis, and weakness. This resident developed a full-thickness wound on the left third toe with serosanguinous drainage, erythema, exposed bone, tenderness, warmth, and slight edema. A wound nurse practitioner ordered clindamycin and transfer to the emergency room for suspected bone involvement and infection; the resident returned on doxycycline for wound infection. The resident was entered on the infection log as meeting McGeer criteria for cellulitis/soft tissue/wound infection, but the McGeer Infection Report Form showed only redness and swelling were documented. The Infection Preventionist incorrectly marked that the infection met McGeer criteria despite only two signs and symptoms being present, instead of the required four, and stated she had been told only one sign or symptom was needed and that she had not done infection control since 2019. Another resident, admitted with diagnoses including above-knee amputation, anxiety disorder, diabetes, hypertension, hyperlipidemia, major depressive disorder, and muscle weakness, was started on Bactrim DS and topical mupirocin for a large, purple/red, hard abscess under the right breast that was warm to touch and afebrile at the time. This resident was not initially entered on the infection log, and no McGeer Infection Report Form was completed when the antibiotic was ordered because the Infection Preventionist was off duty. Several days later, nursing documentation described drainage, yellow slough, surrounding redness, warmth, and a temperature of 99.2°F, and a McGeer Infection Report Form was then completed. The form indicated heat, redness, serous drainage, and fever, but the Infection Preventionist did not indicate on the form whether criteria were met, and the infection log was later revised to show the resident did not meet criteria. The DON later verified that only one temperature above 99°F had been documented, which would not meet the constitutional fever criterion, making the fever marking an error. A third resident was receiving Levaquin for a “culture infection” on an every-48-hour schedule. This resident was not initially listed on the infection log, and there was no completed McGeer Infection Report Form at the time of surveyor review. The Infection Preventionist stated she had started but not completed the form and believed the resident would not meet criteria because of an upper respiratory infection. A subsequent infection report form documented pneumonia, with all three required criteria checked: chest radiograph interpreted as pneumonia or new infiltrate, new or changed lung exam abnormalities, and leukocytosis. A revised infection log then listed this resident as meeting criteria for antibiotic use, with pneumonia, hypoxia, shortness of breath, and gram-negative rods noted. The Infection Preventionist confirmed that the McGeer Infection Report Form was not completed in a timely manner to determine antibiotic stewardship for this resident and that it was not timely identified whether the physician needed to be called if criteria were not met. Review of the facility’s Antibiotic Stewardship Program policy, revised in 2017, showed that all residents with newly diagnosed infections using antibiotics were to be reviewed for appropriate utilization, including review of infection symptoms prior to initiation, consideration of an antibiotic holiday when there was no proof of review, obtaining and reviewing culture and sensitivity results, and discussing results and treatment recommendations with the primary care physician to ensure responsible antibiotic use. The policy also required prescribers to document dose, duration, and indication for all antibiotic use. Despite this policy, the survey findings demonstrated that residents were started on antibiotics without timely or accurate application of McGeer criteria, infection logs were incomplete or delayed, and the Infection Preventionist lacked current knowledge of the criteria and did not consistently communicate with physicians regarding antibiotic appropriateness when criteria were not met.
Failure to Implement Antibiotic Stewardship for Suspected UTIs
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship program to ensure appropriate use of antibiotics, specifically related to urinary tract infection (UTI) management. For one resident admitted in December 2024 and readmitted in September 2025 with diagnoses including heart failure, COPD, and diabetes mellitus, record review showed no documentation of any UTI signs or symptoms in the medical record. Despite this, the infection control log for January 2026 listed the resident as having acquired an in-house UTI and receiving antibiotics from January 27, 2026, to February 3, 2026, and indicated that McGeer’s criteria were met. The DON confirmed there was no documentation of UTI signs or symptoms, and although a urinalysis was ordered on January 19, 2026, there was no documentation of signs and symptoms or a completed McGeer’s assessment for UTI. A second resident, admitted in August 2023 and readmitted in March 2024 with diagnoses including chronic kidney disease, major depressive disorder, and anxiety disorder, similarly had no documentation of UTI signs or symptoms in the medical record. The quarterly MDS showed this resident had intact cognition and was dependent on staff for ADLs. The facility’s infection control log for February 2026 recorded that this resident acquired an in-house UTI and was on antibiotics from February 1, 2026, to February 6, 2026, and again indicated that McGeer’s criteria were met. The DON verified there was no documentation of UTI signs or symptoms and no McGeer’s assessment completed for this UTI. Review of the facility’s undated Antibiotic Stewardship Program policy showed that the infection control nurse or designee was responsible for infection control line listing and review of antibiotic utilization to ensure appropriate prescribing and use of antibiotics, which was not carried out as required in these cases.
Failure to Implement Antibiotic Stewardship and Apply McGeer’s Criteria for UTI Management
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship policy and McGeer’s criteria when monitoring and managing antibiotic use for residents with suspected urinary tract infections (UTIs). For one resident with malignant neoplasm of the urethra, chronic kidney disease, obstructive and reflux uropathy, and an indwelling catheter, the catheter was accidentally dislodged and replaced in the emergency room, where a urinalysis showed blood and leukocytes and the resident was diagnosed with a UTI. She was started on Cefuroxime, which was continued despite the resident denying dysuria, fever, flank pain, chest pain, or dyspnea, and despite a subsequent urine culture showing pseudomonas aeruginosa at levels below McGeer’s threshold and without Cefuroxime listed as an effective antibiotic. The facility’s antibiotic stewardship evaluation documented that McGeer’s criteria were not met but still recorded a physician justification that did not specify which physician provided it or what symptoms were present. For a second resident with diabetes, chronic kidney disease, and an indwelling catheter, an admission order was written for Keflex for a UTI. The facility’s antibiotic stewardship evaluation stated that the resident had a UTI with onset that day, was not experiencing pain related to the infection, and had repeated oral temperatures of 99°F, and concluded that McGeer’s criteria were met based on fevers and a urine culture with at least 10^5 CFU/mL. The urine culture later showed >100,000 CFU/mL of proteus mirabilis, but the sensitivity report did not include Keflex, and facility documentation noted that Keflex’s effectiveness for UTIs depends on local resistance patterns and that culture and sensitivity testing is crucial before prescribing. Keflex was administered until it was discontinued early due to diarrhea, and there was no evidence that the physician reviewed the continued use of Keflex when it was not listed on the sensitivity report. The DON later stated that the stewardship evaluation was marked in error, as the resident had only one slightly elevated temperature and not repeated fevers. For a third resident with diabetes and hypertension, who had a catheter and was sent to the emergency room for decreased urinary output and concern for kidney injury, hospital records documented burning urinary pain but also noted denial of abdominal or flank discomfort, fevers, chills, hematuria, or dysuria. The resident was started on Macrobid for a UTI and completed a five-day course, and a physician progress note indicated the plan to continue Macrobid and follow up on urine culture results to ensure appropriate coverage. The subsequent urine culture showed 10,000–50,000 CFU/mL of pseudomonas aeruginosa and escherichia coli, which did not meet McGeer’s threshold of >100,000 CFU/mL, and there was no evidence of physician follow-up on the antibiotic choice in light of these results. The DON confirmed that an antibiotic stewardship evaluation was not completed for this antibiotic use and that the physician did not reassess the need for Macrobid when the culture results did not support antibiotic therapy, contrary to the facility’s policy requiring communication of culture and sensitivity results to determine whether antibiotics should be started, continued, modified, or discontinued.
Failure to Implement Effective Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program when a resident returned from the hospital with a new order for Keflex to treat a urinary tract infection (UTI). The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and chronic kidney disease, was sent to the emergency room for chest pain and returned with a UTI diagnosis and an order for Keflex. Hospital records showed that a urine culture identified Enterobacter Cloacae as the causative organism, which was not sensitive to Keflex. Despite this, the resident received the full seven-day course of Keflex as ordered. The acting Infection Preventionist (IP) at the facility was responsible for reviewing antibiotic use for residents returning from the hospital. The IP identified that the organism causing the UTI was not sensitive to the prescribed antibiotic and completed an antibiotic time-out, reaching out to the resident's physician. However, the Antibiotic Time Out report incorrectly documented the organism as E. coli, for which Keflex would have been appropriate, rather than Enterobacter Cloacae. The physician was informed of the incorrect organism and did not respond until the antibiotic course was nearly complete, instructing to finish the course despite its ineffectiveness against the identified organism. Facility policy required the IP to monitor antibiotic use, review laboratory results, and ensure antibiotics were appropriate for the identified infection. The policy also stated that the Medical Director was responsible for setting standards for antibiotic prescribing and overseeing adherence. In this case, there was no evidence that the antibiotic was changed to one effective against the organism identified in the culture, and the resident received an ineffective antibiotic regimen, contrary to the facility's antibiotic stewardship policy.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, specifically by not performing antibiotic time out assessments for a resident who had multiple courses of antibiotics. The resident, who had diagnoses including dementia, pressure ulcers, a history of urinary tract infections, and cellulitis of the right great toe, was prescribed antibiotics on several occasions for various infections such as urinary tract infections, clostridium difficile, cellulitis, toe infection, increased white blood count, conjunctivitis, and osteomyelitis. Despite these multiple antibiotic treatments, the medical record review revealed that antibiotic time out assessments were not completed on several dates when antibiotics were initiated. An interview with the Assistant Director of Nursing confirmed that staff did not perform the required antibiotic time out assessments for the resident on the specified dates. The facility's policy stated that the infection prevention and control nurse was responsible for tracking all antibiotic starts and monitoring adherence to criteria during infection management. The lack of these assessments was verified and acknowledged by facility staff, representing a failure to follow the established antibiotic stewardship program.
Failure to Monitor and Address Infection Patterns
Penalty
Summary
The facility failed to properly monitor and address patterns and trends of known infections, as evidenced by a review of infection control logs from June to August 2025. During this period, multiple infections were documented, including urinary tract infections, skin infections, fungal infections, osteomyelitis, and respiratory infections, with several instances of the same type of infection occurring in the same units. Despite these documented patterns and trends, there was no evidence that the facility took action to address them, such as staff education, monitoring, or auditing of care practices. An interview with a registered nurse confirmed that no interventions or educational efforts had been implemented in response to these infection trends, and the facility's infection control documentation lacked any indication of efforts to reduce the likelihood of infection spread among the 112 residents.
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