Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of documented surveillance for antibiotic use over a four-month period. The review of facility documentation, policies, and CDC guidelines revealed that the facility did not utilize any surveillance tools for monitoring antibiotic use, which is a critical component of an antibiotic stewardship program. The facility's antibiotic tracking log from August to November 2024 showed no evidence of consultant pharmacist reports, laboratory reports, infection descriptions, or details on antibiotic dose and duration, which are necessary for effective monitoring and management of antibiotic use. An interview with the infection preventionist confirmed that the facility's antibiotic stewardship program did not include reports or data from the pharmacist or laboratory. This lack of integration and monitoring indicates a failure to adhere to CDC guidelines and facility policies, which require the inclusion of cultural reports, sensitivity data, and antibiotic usage reviews in surveillance activities. The absence of these critical components in the facility's antibiotic stewardship program led to the deficiency identified during the survey.
Plan Of Correction
The facility will complete an audit of antibiotics stewardship including all new and current antibiotic usage for the last 15 days to be completed by the Infection Preventionist. All residents on antibiotics have the potential to be affected. Residents receiving or that have received antibiotics in the last 15 days will be audited by the IPN for proper surveillance and tracking. Education provided to the infection preventionist on Antibiotic stewardship program to include tracker that consists of surveilling infection description, antibiotic dose and duration, and lab or pharmacy reports. The facility will utilize a tracker that consists of surveilling infection description, antibiotic dose and duration, and lab or pharmacy reports. Director of Nursing / designee will conduct audits of antibiotic stewardship surveillance program to monitor for proper tracking. Audits will be completed weekly x4 weeks then monthly x2 months. Findings will be reported to the QAPI committee.