Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as required by regulations, specifically for the months of April through July 2024. The facility's infection control policies, reviewed on January 15, 2024, indicated that antibiotics should be prescribed and administered under the guidance of the facility's antibiotic stewardship program. This program is intended to monitor the use of antibiotics among residents. However, a review of the facility's infection control surveillance records from April 2024 to January 2025 revealed a lack of documentation indicating that antibiotic monitoring was conducted during the specified four-month period. During an interview on February 5, 2024, the Vice President of Clinical Services confirmed the absence of a system of surveillance to monitor antibiotic use and lab correlation for infections during these months. The facility was unable to produce tracking records for antibiotic use for April, May, June, and July 2024. This deficiency was noted as a failure to adhere to the facility's own policies and the regulatory requirements for an antibiotic stewardship program.
Plan Of Correction
The facility's Infection Preventionist will be re-educated by the DON/Designee on job description and Antibiotic Stewardship Program to ensure proper compliance. The DON/Designee will audit antibiotics monthly x 3 months to ensure compliance with the facility's antibiotic stewardship program. The results of the education and audits will be shared at the monthly QAPI meeting for review and approval.