Failure in Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program that adhered to the McGeer criteria for antibiotic usage over a four-month period. During this time, the facility did not adequately document whether infections met the criteria for appropriate antibiotic treatment. Specifically, in January 2024, only one McGeer surveillance form was completed despite 36 facility-acquired infections being documented. In February, no McGeer forms were filled out for 24 documented infections. Similarly, in March, no forms were completed for 18 infections, and in April, only two forms were filled out for 23 infections. This lack of documentation meant that it was unclear if the infections met the criteria for antibiotic treatment. Interviews with facility staff revealed that the unit managers were responsible for completing the McGeer criteria forms for each facility-acquired infection. However, the Infection Preventionist (IP) nurse noted that these forms were not submitted regularly during the months in question. The Director of Nursing (DON) expected the unit managers to complete and forward these forms to the IP nurse for review. The facility's policy on Antibiotic Stewardship emphasized the importance of appropriate antibiotic use to prevent drug-resistant bacteria, increased hospitalizations, higher mortality, and escalating costs. Despite this policy, the facility's failure to document and review infections according to the McGeer criteria potentially led to unnecessary antibiotic prescriptions.
Plan Of Correction
No residents were identified to be affected by the deficient practice. All residents have the potential to be affected by the deficient practice. All nurses and the Infection Preventionist nurse were in-serviced by the Director of Nursing on completing and submitting the Revised McGeer Criteria for Infection Surveillance Checklist. A Revised McGeer Criteria for Infection Surveillance Checklist is to be completed for each facility acquired infection by unit managers or designee. The Infection Preventionist nurse will ensure a Revised McGeer Criteria for Infection Surveillance Checklist is collected and reviewed for each facility acquired infection. The Director of Nursing will audit the Antibiotic Stewardship Program monthly to ensure a Revised McGeer Criteria for Infection Surveillance Checklist is completed for each facility acquired infection. Results of these audits will be reported to the Administrator on a monthly basis. All findings will be reported and reviewed monthly and reported quarterly during the QAPI meeting for the next 2 quarters by the DON or designee to the QAPI committee. Evaluation by the committee will determine the continuing frequency of audits.