Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of congestive heart failure, was prescribed ciprofloxacin based on a urinalysis indicating a possible UTI. However, subsequent urine culture and sensitivity tests revealed that the bacteria were resistant to ciprofloxacin and other antibiotics initially considered. Despite this, there was no change in the resident's medication, and the ciprofloxacin treatment continued without documented clinical rationale. The facility's policy required monitoring and adjusting antibiotic use based on sensitivity tests, a process overseen by the Medical Director and Consultant Pharmacist. However, the laboratory results indicating resistance were not reviewed or acted upon, leading to the continued use of an ineffective antibiotic. The Director of Nursing acknowledged that the facility's expectation was to adjust antibiotic use according to sensitivity tests, which was not done in this case.
Plan Of Correction
1. Resident 98 did not have any adverse effects related to the antibiotic that was administered. Urine culture sensitivity results were reviewed with the MD who advised to not repeat the UA as resident was asymptomatic and already completed the ordered antibiotic. 2. A Comprehensive review of all current residents on an antibiotic for a positive Urinary Tract Infection will be reviewed to ensure that Culture results have been reviewed with the MD timely and that appropriate Medication is in place. 3. The facility will take further steps to ensure that the problem does not re-occur by in-servicing licensed nursing staff on F Tag 881 with a focus on UTI's/Antibiotics as well as facility policy IC 402 Antibiotic Stewardship. 4. Compliance will be monitored by the Director of Nursing / Designee using an Antibiotic Stewardship Audit to review 5 residents weekly x 3 weeks then monthly x 2 months to ensure that UA results were reviewed with MD timely and correct Antibiotic is in place, with audit results being forwarded to the QAA committee to determine the need for further follow up / monitoring.