Failure in Antibiotic Stewardship Program Documentation
Summary
The facility failed to maintain a comprehensive review of antibiotic prescribing practices and documentation of the antibiotic stewardship program's efforts from January 2024 to September 2024. The policies in place required that antibiotics be prescribed and administered under the guidance of the facility's antibiotic stewardship program, with complete orders including drug name, dose, frequency, duration, route, and indications of use. Additionally, when a nurse communicated a suspected infection to a prescriber, specific information was to be provided, such as signs and symptoms, hydration status, and current medication list. However, the facility did not complete the required tracking and trending of antibiotic use, as evidenced by the absence of completed Monthly Healthcare Associated Infection Summary Reports for each month in 2024. The Infection Control Preventionist, who started working at the facility on October 1, 2024, indicated that her duties included monitoring personal protective equipment and conducting infection control assessments. Despite these responsibilities, the facility's antibiotic surveillance tracking form was not utilized to document antibiotic regimens, including details such as resident name, unit, date symptoms appeared, and antibiotic start and stop dates. This lack of documentation and review of antibiotic use had the potential to affect any resident prescribed antibiotics, as the facility did not adhere to its own policies for antibiotic stewardship and surveillance.
Penalty
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The facility failed to maintain an effective antibiotic stewardship program when the ICP, who was hired for infection control, reported spending most of their time working as a floor nurse due to staffing shortages and could not consistently perform stewardship duties. The ICP described intended practices such as using McGeer's criteria, audits, and an infection screening tool, but review of infection control records showed missing documentation of resident lab results, clinicians' rationale for antibiotic use, and criteria supporting prescribed antibiotics. The ICP stated the program was only compliant for one month when staffing was adequate, and that requests for additional help and training from corporate were denied. When surveyors requested the antibiotic stewardship policy, no additional information was provided.
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 core elements of an antibiotic stewardship program within its infection prevention and control system for a census of 29 residents, including a sample of 12. The Infection Control Log for a one-year period lacked documentation of organism identification, duration of prescribed antibiotics, and the infections treated, and this information could not be produced when requested. The Infection Preventionist, an administrative nurse, stated she only tracked which residents were on antibiotics in the EMR and was unable to provide tracking and trending data, noting that floor nurses were not completing the infection tracking documents. These practices did not conform to the facility’s Infection Preventionist policy, which required effective management of the infection prevention program using evidence-based practices and compliance with CMS and state regulations.
A resident received Tobradexame eye drops, a steroid/antibiotic combination, under an order that did not include a treatment duration as required by the facility’s Antibiotic Stewardship Program (ASP) policy. The ASP policy specified that all antibiotic orders must include dose, duration, route, and indication and be tracked in the medical record. Review of the Treatment Administration Record showed the PRN Tobradexame order for blepharitis had a start date but no stop date, and the medication was administered on multiple days for red eyes. In an interview, the DON confirmed that all antibiotic orders were supposed to include a duration and acknowledged that this order did not meet that requirement.
The facility failed to follow its Antibiotic Stewardship Policy and McGeer’s Criteria when initiating antibiotic therapy for a suspected UTI in a resident with multiple diagnoses, including adult failure to thrive and a need for assistance with personal care. The resident’s care plan directed monitoring for specific urinary and systemic symptoms, and the resident was later noted to be increasingly lethargic with decreased muscle function. A provider ordered lab tests, including a urinalysis with culture and sensitivity, along with cefdinir for a UTI diagnosis, and the antibiotic was started before culture and sensitivity results were available. The urine culture and sensitivity were completed several days after antibiotic initiation, and the DON later confirmed the resident did not meet McGeer’s criteria for antibiotic treatment for UTI.
The facility failed to follow its antibiotic stewardship and infection screening processes for three residents treated for suspected or documented UTIs. One resident with quadriplegia, immunodeficiency, and a suprapubic catheter received multiple antibiotics, including Macrobid, Levofloxacin, and Methenamine Hippurate, without documented monitoring of UTI symptoms or side effects, and with prophylactic therapy ordered despite a negative infection screening and no defined stop date. A second resident with Parkinson’s disease and moderate cognitive deficits was started on Cefuroxime Axetil for dysuria and a urinalysis showing many bacteria, but no Infection Screening Evaluation was completed before therapy and only one late progress note documented UTI symptom monitoring. A third resident with diabetes and moderate cognitive deficits was prescribed Ciprofloxacin for confusion and a positive urine culture, even though confusion alone did not meet McGeer criteria for UTI, and no Infection Screening Evaluation or ongoing symptom monitoring was documented during treatment.
Failure to Maintain an Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that promotes appropriate antibiotic use and includes a system of monitoring. During an interview, the ICP stated that their role included ensuring residents met McGeer's criteria for antibiotic use, confirming staff followed protocols and procedures, educating staff on infection control policies, and using audits and an infection screening tool to determine if residents met criteria for antibiotics. The ICP reported they began the position in November 2025 and were hired specifically for infection control. However, the ICP explained that due to staffing shortages they were frequently assigned to work as a floor nurse and could only perform infection control duties when time allowed. Review of the infection control books showed that requested information, including specific resident lab results, clinicians' rationale for antibiotic use, and documentation of McGeer's criteria supporting prescribed antibiotics, was not available. The ICP acknowledged that the program was not compliant except for one month when staffing was adequate. The ICP also reported that they had requested additional help and training from corporate staff but were denied, and that they had functioned more as a floor nurse than an ICP. When the antibiotic stewardship policy was requested, no additional information was provided.
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 Core Elements of Antibiotic Stewardship
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control program for its 29 residents, 12 of whom were included in the sample. Review of the Infection Control Log for tracking and trending infections from March 2025 through February 2026 showed no documentation of organism identification, duration of prescribed antibiotics, or the specific infections being treated, and the facility was unable to provide this information when requested. The Infection Preventionist, who was also an administrative nurse, reported that she only tracked which residents were taking antibiotics in the EMR and confirmed she could not provide tracking and trending data for antibiotic use. She stated that floor nurses were expected to open the infection document for tracking but were not completing the form, leaving her with only records of antibiotics that residents had taken for infections, without the additional required details. This practice did not align with the facility’s Infection Preventionist policy, which assigned responsibility for effective direction, management, and operation of the infection prevention program, including use of evidence-based practices and compliance with CMS and state regulatory requirements. No additional resident-specific medical histories or conditions at the time of the deficiency were provided in the report.
Antibiotic Order Lacked Required Duration Under Facility ASP Policy
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) requirements when ordering and administering an antibiotic medication for Resident 26. The facility’s undated Antibiotic Stewardship Policy stated that all antibiotic orders must include dose, duration, route, and indication, and that these orders would be tracked and kept in the medical record. Record review of Resident 26’s March 2026 Treatment Administration Record (TAR) showed an order for Tobradexame suspension, a steroid/antibiotic combination, to be instilled as one drop to both eyes four times daily as needed for blepharitis, with a start date of 08/25/25 but no stop date documented. The TAR further showed that the resident received the eye drops on March 4 and March 5, 2026, for red eyes, despite the absence of a documented duration for the antibiotic therapy. In an interview, the DON confirmed that all antibiotic orders were required to have a duration and acknowledged that Resident 26’s Tobradexame order did not include this required element. This deficiency occurred in the context of a facility census of 27 residents and was identified through record review and staff interview, demonstrating that the specific antibiotic order for Resident 26 was not written in accordance with the facility’s established ASP policy regarding inclusion of treatment duration.
Failure to Follow Antibiotic Stewardship and McGeer’s Criteria for UTI Treatment
Penalty
Summary
The deficiency involves failure to follow the facility’s Antibiotic Stewardship Policy and McGeer’s Criteria when initiating antibiotic therapy for a suspected urinary tract infection (UTI). The policy, revised 8/10/25, states the facility focuses on improving antibiotic use through an Antibiotic Stewardship Program, utilizes McGeer’s Criteria to validate infections, and routinely reviews culture and sensitivity reports as part of infection surveillance. McGeer’s Criteria for UTI without an indwelling catheter require at least one specified clinical sign or symptom and at least one qualifying microbiologic criterion. Despite these requirements, the facility initiated antibiotic treatment before culture and sensitivity results were available and in a situation later confirmed by the DON not to meet McGeer’s criteria for UTI. The resident involved was readmitted with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care. The resident’s care plan, revised 3/27/25, directed staff to encourage fluids and monitor for specific urinary and systemic symptoms such as urinary frequency, malaise, foul-smelling urine, dysuria, fever, nausea, vomiting, flank pain, suprapubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes. On 3/27/25 at 4:43 PM, the resident was observed to be increasingly lethargic with decreased muscle function, and the provider was notified. New orders were obtained for a CBC, CMP, urinalysis with culture and sensitivity, and cefdinir 300 mg by mouth twice daily for 5 days for a diagnosis of UTI. The urine specimen was collected earlier that day, and the culture and sensitivity were not completed until 3/29/25, three days after antibiotics were started. On 3/5/26 at 4:12 PM, the DON confirmed the resident did not meet McGeer’s criteria for antibiotics for a UTI.
Failure to Implement Effective UTI Antibiotic Stewardship and Symptom Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and antibiotic stewardship process for three residents with suspected or documented urinary tract infections (UTIs). For one resident with quadriplegia, immunodeficiency, and a suprapubic catheter, the facility used an Infection Screening Evaluation tool as part of its surveillance program. On 1/12/26, this resident’s screening showed a score of 50 with acute dysuria, and a urine culture from 1/9/26 showed Gram Positive Cocci with a colony count of 50,000–90,000. The physician ordered Macrobid from 1/9/26 through 1/16/26 for UTI treatment, but there was no supporting documentation that nursing staff monitored UTI symptoms or potential side effects during the antibiotic course. For the same resident, an Infection Screening Evaluation completed on 2/11/26 showed a score of zero, indicating no symptoms of infection, yet the resident was prescribed Levofloxacin from 2/10/26 through 2/17/26 for UTI and Methenamine Hippurate for infection prophylaxis without a stop date. The Methenamine Hippurate order did not include a documented diagnosis supporting infection prophylaxis, and again there was no documentation of monitoring for UTI symptoms or side effects while the resident was on these antibiotics. The Infection Prevention (IP) nurse acknowledged that the resident should have been monitored for signs and symptoms of UTI during antibiotic therapy and that the prophylactic antibiotic order lacked a defined duration and clear diagnostic basis. A second resident with Parkinson’s disease and moderate cognitive deficits complained of dysuria on 2/2/26 and had a urinalysis on 2/3/26 showing many bacteria. The resident, who was incontinent and did not have a urinary catheter, was prescribed Cefuroxime Axetil for seven days beginning 2/4/26 for a suspected UTI. However, the facility did not complete an Infection Screening Evaluation prior to starting the antibiotic to determine if McGeer criteria for UTI were met. During the antibiotic course, only one progress note dated 2/10/26 documented monitoring of UTI symptoms, stating the resident continued on antibiotics for UTI with no complaint of bladder discomfort, and no consistent monitoring of UTI symptoms was documented. A third resident with diabetes mellitus and moderate cognitive deficits was prescribed Ciprofloxacin from 2/8/26 through 2/15/26 for a suspected UTI based on confusion and a urinalysis with a colony count greater than 100,000 E. coli. The IP nurse stated that, according to McGeer criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support a UTI diagnosis, and confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. For this resident, the Infection Screening Evaluation was not completed prior to starting antibiotics, and there was no documented monitoring of UTI symptoms while on treatment. Across all three residents, the facility’s documented practices did not align with its Antibiotic Stewardship policy, which required complete antibiotic orders including duration and the use of clinical criteria and evaluation tools before and during antibiotic therapy.
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