Failure in Antibiotic Stewardship Leads to Resident Harm
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in harm to a resident. The resident had a urine culture that identified the bacteria as resistant to Nitrofurantoin (Macrobid). Despite this, the attending physician ordered Macrobid to treat the urinary tract infection (UTI). The resident received the full course of Macrobid, but her symptoms did not improve. Upon the family's request for a dose increase, the facility reviewed the culture again and discovered the error. The antibiotic was then changed to Bactrim, to which the bacteria was susceptible. The resident was later hospitalized with sepsis, metabolic encephalopathy secondary to UTI, acute kidney injury, and acute urinary retention. The facility's Antibiotic Stewardship Plan Policy and Procedure was not followed, as the Infection Preventionist did not verify the physician's order against the culture results. The Director of Nursing acknowledged that the physician misread the culture, and the Infection Preventionist did not follow her usual process of verifying and communicating the culture results. This oversight led to the resident receiving an ineffective antibiotic, contributing to her hospitalization.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Inappropriate Prophylactic Antibiotic Use: A resident with severe cognitive impairment, CKD, diabetes, and a history of urinary incontinence and recurrent UTIs was placed on chronic Macrobid for UTI prevention despite documentation that chronic antibiotic use was not recommended and that UTIs had decreased with hydration and scheduled toileting. The chart lacked justification, the order had no end date or reassessment date, and staff reported the resident had no UTI sx while the family continued to request prophylactic antibiotics. The pharmacist and IP confirmed the antibiotic stewardship criteria were not being followed.
A resident receiving IV meropenem for an abdominal abscess after surgery missed 27 ordered doses when the antibiotic was stopped without explanation and later restarted after the ID office called the facility. The resident also did not receive ordered weekly CBC, CMP, and CRP labs while on IV antibiotics, and the DON stated the labs had not been completed until the ID office reported they were missing.
Antibiotic stewardship reviews were not completed appropriately for three residents treated for suspected or documented UTIs. One resident received Meropenem IV, another received Ciprofloxacin, and a third received Macrobid, but the required SDCF criteria were incomplete or reviewed after the antibiotic courses ended. The records also lacked documented communication with the hospital or physician about missing or non-qualifying urine culture results, despite orders for UA and C&S and diagnoses including ESBL resistance, UTI, dementia, and MRSA carrier status.
Antibiotic Stewardship Not Followed for Prophylactic Bactrim Use: A resident with Alzheimer’s disease and MS was ordered Bactrim 800-160 mg daily indefinitely for UTI prophylaxis. The ADON said the medication was being used as a UTI preventative, but there was no documented criteria, written provider rationale, or documentation of other interventions tried; the DON said the resident met McGeer’s criteria for a prophylactic antibiotic.
The facility failed to maintain its antibiotic stewardship program and did not document monthly antimicrobial monitoring, tracking, trending, or utilization review. For one resident with epilepsy and parkinsonism, Macrobid was ordered for a UTI, but there was no documented McGeer Criteria assessment or supporting clinical signs and symptoms before the antibiotic was started; the culture later showed mixed normal urogenital flora and the antibiotic was discontinued after lab review.
Failure to monitor antibiotic use: The facility did not have an antibiotic stewardship process in place to review indications, dosage, duration, trends, or resistance. The infection control binder contained no antibiotic tracking or 72-hour time-outs, and the RN infection preventionist and interim DON both stated they could not find evidence that antibiotic use had been tracked or monitored.
Inappropriate Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure appropriate antibiotic use for a resident with severe cognitive impairment, diabetes, chronic kidney disease, and Alzheimer’s disease who had a history of urinary incontinence and prior recurrent UTIs. Her record showed that after admission she had only one UTI in a 6-month period, and the NP documented that chronic antibiotic use for prevention of UTIs was not recommended because of her age and kidney impact. Urology later noted that UTIs had decreased in frequency since admission, attributed improvement to increased fluid intake, and recommended hydration, regular pad changes, scheduled toileting, cranberry tablets, and consideration of vaginal estrogen cream rather than chronic antibiotic therapy. Despite those findings, a physician later documented a desire to give Macrobid 100 mg daily to prevent bladder infection and entered the order without an end date or reassessment date. The resident had also recently been hospitalized with septic shock secondary to acute cystitis, E. coli, chronic kidney disease, acute kidney injury, acute cystitis with hematuria, and gram-negative bacteremia, and was discharged on a short course of ciprofloxacin and cranberry. The infection preventionist reported the family continued to request prophylactic antibiotics even though the resident had no signs or symptoms of UTI, and that education had been provided by nursing staff, the NP, and urology. The pharmacist confirmed the medical record lacked documentation to justify prophylactic antibiotic use and that the order had no end date or reassessment date. The infection preventionist also reported the resident was experiencing increased peripheral edema believed to be a side effect of the antibiotic, but the physician continued the order despite no identified UTI symptoms. The facility’s antibiotic stewardship policy required monitoring of antibiotic use, identification of potentially inappropriate or prophylactic use, and tracking of outcomes, but the report identified that medical staff continued to order antibiotics even when criteria were not met.
Failure to Administer IV Antibiotic and Complete Ordered Weekly Labs
Penalty
Summary
The facility failed to administer meropenem and monitor ordered labs for one resident receiving IV antibiotics for an abdominal abscess after surgery. The resident was a Spanish-speaking male with a history of a surgically repaired small bowel obstruction with colostomy, an abdominal abscess requiring IV antibiotics, and prior brain bleed with craniotomy, aphasia, and weakness on one side. A hospital transfer summary ordered meropenem 1 gram IVPB every 8 hours for 42 doses, with the final duration to be determined at an outpatient infectious disease follow-up appointment. An infectious disease physician note ordered continuation of meropenem 1 gram IV every 8 hours, a CT scan, weekly CBC with differential, CMP, and CRP while on IV antibiotics, and faxing the results to the office. The EHR showed no lab results, and the DON stated the weekly labs had not been completed until the ID office called the facility to report they were missing. The DON also stated she did not know why the IV antibiotic had been discontinued, and the antibiotic was later restarted after the call from the ID office. The resident missed 27 ordered doses of antibiotics.
Antibiotic Stewardship Review Not Completed Timely for Three Residents
Penalty
Summary
The facility failed to follow its antibiotic stewardship program by not appropriately reviewing antibiotic use for three residents who received treatment for suspected or documented UTIs. Resident 2 was admitted and later readmitted with diagnoses including ESBL resistance and UTI, had severely impaired cognitive skills, and was dependent in activities of daily living. The resident received Meropenem IV for UTI, but the Surveillance Data Collection Form (SDCF) showed Criteria 1 was checked while Criteria 2, the required urine culture criterion for residents with indwelling catheters, was left blank. The SDCF was completed and signed after the antibiotic course had already ended, and the record did not show documented communication with the hospital regarding urine culture results. Resident 15 was admitted with diagnoses including UTI and ESBL resistance and had intact cognitive skills but required maximal assistance for several activities of daily living. The resident was ordered Ciprofloxacin 500 mg by mouth twice daily for UTI symptoms for seven days and received the medication as ordered. However, the urine culture result dated 5/6/2026 indicated the culture was not processed and did not meet NHSN UTI criteria, and the SDCF showed Criteria 1 was checked while Criteria 2 was blank because the culture did not meet surveillance criteria due to mixed flora growth. The SDCF was completed after the antibiotic course was finished, and the progress notes did not document communication with the physician about the urine culture results. Resident 77 had diagnoses including dementia and carrier or suspected carrier of MRSA, with severely impaired cognitive skills and impairment of both upper extremities. The physician ordered urine UA and culture and sensitivity, but the laboratory record showed urinalysis results without urine culture results. The resident was then ordered Macrobid 100 mg twice daily for UTI for seven days and received the medication, while the SDCF showed Criteria 1 was checked and Criteria 2 was left blank. The progress notes did not document communication to the physician about the absence of urine culture, and the SDCF was completed and signed after the antibiotic course had already been completed.
Antibiotic Stewardship Not Followed for Prophylactic Bactrim Use
Penalty
Summary
The facility failed to promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy and by providing a written rationale from the provider when an antibiotic was used despite criteria to determine appropriate use. For Resident #32, a female with Alzheimer’s disease and multiple sclerosis and a BIMS score of 09 indicating moderate cognitive impairment, the record showed an order for Bactrim 800-160 mg, 1 tablet by mouth daily for prophylactic use indefinitely, with a start date of 03/12/26 and no end date. During interview, the ADON stated the medication was being given as a UTI preventative because the resident had recurrent UTIs and had been placed on IV antibiotics to treat them, but she also stated there were no documented criteria followed, no documented rationale for the antibiotic, and no documentation of other interventions tried. The DON stated the resident had recurrent UTIs and met McGeer’s criteria for a prophylactic antibiotic. The facility policy on Antibiotic Stewardship - Orders for Antibiotics stated appropriate indications for antibiotics include criteria met for clinical definition of active infection or suspected sepsis, and pathogen susceptibility based on culture and sensitivity, or therapy begun while culture is pending.
Failure to Monitor Antibiotic Use and Document Criteria for Treatment
Penalty
Summary
The facility failed to implement and maintain an antibiotic stewardship program and did not conduct or document antibiotic stewardship monitoring for eight months reviewed, from November 2025 through June 2026. The facility policy required monthly review and tracking of antimicrobial prescribing, use, resistance, utilization reports, and surveillance for patterns, trends, and clusters, but the infection control surveillance records contained no documentation that these activities had been completed during any of the eight months reviewed. For Resident 97, who was admitted with diagnoses including epilepsy and parkinsonism, a physician ordered Macrobid 100 mg twice daily for five days for a UTI. The resident received four doses, but the clinical record contained no documentation that a McGeer Criteria assessment had been completed before the antibiotic was started, and there was no documentation supporting the clinical signs or symptoms used to determine that the resident met the facility's criteria for antibiotic treatment. A urinalysis with culture showed minimal bacterial growth with mixed normal urogenital flora, and the provider reviewed the laboratory results and discontinued the antibiotic after the culture did not identify evidence of a UTI.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use, and resistance. Review of the infection control binder showed no antibiotic tracking for correct indications, dosage, duration, resistance, or 72-hour time-outs to review cultures and verify correct antibiotics or resistance to prescribed antibiotics. During interview, the RN who had recently been hired as the infection preventionist stated she had not had time to start an antibiotic stewardship program and could not find any documents from the prior infection preventionist showing that antibiotic usage was being tracked and monitored. The interim DON stated the prior employee responsible for antibiotic stewardship had left on short notice and that there was no evidence of tracking antibiotic usage for correct dosage, duration, resistance, or completion of 72-hour time-outs. The interim DON also stated this was a problem at the facility and that the program would need to be restarted.
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