Failure in Antibiotic Stewardship Leads to Duplicate Dosing
Summary
The facility failed to ensure proper monitoring of antibiotic use under its antibiotic stewardship program, resulting in a resident receiving duplicate doses of the same antibiotic. Resident 156, who had a history of hemiplegia, diabetes, heart failure, and chronic kidney disease, was prescribed Augmentin for pneumonia. Initially, a dose of 500-125 mg was ordered, but a subsequent order increased the dosage to 875-125 mg without discontinuing the initial order. This led to the resident receiving both dosages concurrently, which was inappropriate given her renal function. The Assistant Director of Nursing/Infection Preventionist was unaware of the duplicate dosing and did not investigate the higher dosage. The pharmacy did not receive a discontinue order for the initial dose, resulting in both dosages appearing on the facility's Medication Administration Record. Despite daily reviews of new antibiotic orders, the clinical team failed to identify and address the duplicate dosing. The facility's policy on antibiotic stewardship was not effectively implemented, as evidenced by the lack of action to prevent the medication error that occurred.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Implement Antibiotic Stewardship Program: The facility failed to implement an antibiotic stewardship program for eight of 12 months. Review of the infection control records showed no documented antibiotic monitoring or appropriate use tracking during that period. The DON stated she had not been overseeing infection control until May and that if the binders did not contain the information, then the facility did not have it. A Regional Director later found an antibiotic stewardship binder with lab reports and prior survey information, but no facility antibiotic tracking, and the NHA and DON confirmed the lapse.
A resident with severe cognitive impairment, incontinence, and multiple chronic conditions received repeated antibiotic courses for suspected UTI/cystitis, including cephalexin, Rocephin, and nitrofurantoin. The facility used a UTI SBAR process and had an antibiotic stewardship policy requiring Loeb criteria review, a 72-hour reassessment, and documentation of the antibiotic time-out, but the record lacked the required reassessments and further urine testing/culture results. Staff described the process as informal, and the DON could not provide the SBAR forms sent to the PCP.
Failure to Use Antibiotic Stewardship Criteria: The facility did not have an effective Antibiotic Stewardship Program in place. Infection logs showed McGeers criteria were not used to determine whether antibiotics were justified, and the IP stated she relied on the physician order when an infection was not cultured. The IP also verified that McGeers or any other infection criteria had not been used and that the facility was not doing antibiotic stewardship, despite the facility policy requiring use of McGeer's criteria or equivalent screening.
Failure to implement the antibiotic stewardship program affected all residents. The facility’s protocol required infection assessment using standardized criteria, use of LOBES minimum criteria before starting antibiotics, staff education, and antibiotic orders with indication, dose, and duration, but records showed no defined diagnostic algorithm, charting not aligned with McGeer's or LOBES criteria, reflex urine cultures without indication, and inconsistent 72-hour reassessment of UTI antibiotic courses. Two residents were reviewed: one had fatigue with labs and UA ordered without meeting criteria, and another had a change in mental status, no infection signs, a UA, and a Cipro order despite not meeting criteria.
Failure to Document Rationale for Ongoing Prophylactic Antibiotic Use: A resident with a hx of recurrent UTIs remained on chronic suppressive Bactrim therapy, and the prescriber continued the antibiotic without written justification after pharmacy requested a periodic risk-versus-benefit review. The NP stated he had not evaluated the ongoing need, the IP/RNCM was unsure why the antibiotic was ordered prophylactically and had not reviewed continuation, and the MAR showed the antibiotic was administered daily as ordered.
Failure to Monitor Antibiotic Use and Stewardship: The facility failed to implement an antibiotic review process to track indications, dosage, duration, resistance, and 72-hour time-outs. Review of the infection control binder showed no evidence of antibiotic tracking, and the ADON and IDON stated there were no documents showing prior monitoring of antibiotic use. The facility policy required culture reports, sensitivity data, and antibiotic usage reviews as part of surveillance activities.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for eight of 12 months, from September 2025 through April 2026. Review of the facility’s Antimicrobial Stewardship Program policy dated 5/4/26 showed the program was intended to focus on avoiding unnecessary or inappropriate antibiotic use and was to be overseen by the Infection Preventionist, Medical Director, Pharmacist, nursing, and leadership. Review of the Infection Prevention and Control Program policy dated 5/4/26 also stated the program included promoting antibiotic stewardship. Review of the facility’s Infection Control Program records for September 2025 through July 2026 found no documented evidence that antibiotic monitoring and appropriate antibiotic use were completed from September 2025 through April 2026. During interview, the DON stated she had not been overseeing infection control until May and said that if the binders did not contain the information, then the facility did not have it. A Regional Director of Clinical Services later found an antibiotic stewardship binder in an office that contained lab reports and prior survey information, but no facility tracking of antibiotics. The NHA and DON then confirmed the facility failed to implement an antibiotic stewardship program for eight of 12 months.
Failure to Follow Antibiotic Stewardship and UTI Reassessment Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocols for a resident with severe cognitive impairment, frequent bowel and bladder incontinence, and diagnoses including Alzheimer’s disease, dementia, abnormal gait and mobility, history of TIA/stroke, and heart disease. The resident’s care plan identified substantial assistance needs for toileting hygiene, bathing, dressing, and other functional abilities, with dependence for most activities and assistance with peri care due to incontinence. The resident received repeated antibiotic treatment for suspected urinary tract infections, including cephalexin, Rocephin, and nitrofurantoin, with one antibiotic later changed because the resident required medications to be crushed and nitrofurantoin could not be crushed. Progress notes documented lethargy, a low-grade temperature, elevated pulse, rhonchi, and an ED return with acute cystitis, followed by additional treatment for cystitis/UTI. The record also noted completion of antibiotic courses and denial of pain or burning, but the medical record lacked further urinalysis or culture results despite three courses of antibiotics during the reviewed period. The facility’s UTI SBAR process required nurses to document vital signs and urinary symptoms, and the antibiotic stewardship policy required use of Loeb criteria, reassessment at 72 hours after antibiotic initiation, and documentation of the antibiotic time-out in the resident record. During interview, the DON stated the consultant pharmacist was responsible for the antibiotic stewardship program, but the pharmacist was unavailable. Staff described an informal process of pushing fluids, monitoring, and notifying the physician quickly, and the RN stated the provider did not feel additional labs were needed and did not want a urinalysis or culture. The DON could not provide the SBAR communication forms sent to the PCP, and the record lacked documented 72-hour reassessments evaluating the continued need, duration, and selection of antibiotic therapy.
Failure to Use Antibiotic Stewardship Criteria
Penalty
Summary
The facility failed to establish and use an appropriate Antibiotic Stewardship Program. Review of the infection control log for May 2026 and June 2026 showed that McGeers criteria were not used to determine whether infections justified antibiotic use. During an interview on 07/15/26, the Infection Preventionist stated that if an infection was not cultured, she only went by what the physician ordered, verified that McGeers criteria were not used at the facility, and stated she had not used McGeers or any other criteria to determine infections since she began in December 2025. She also stated she had no idea whether the antibiotics given were needed or just ordered and verified that the facility was not doing antibiotic stewardship. Review of the facility's Antibiotic Stewardship policy, updated 08/2024, stated that antibiotics would be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program, including use of McGeer's criteria or equivalent infection screening.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for all residents in the facility. Its Antimicrobial Stewardship Protocol required assessment for infection using standardized tools and criteria, use of LOBES minimum criteria before starting antibiotics, education for prescribing practitioners and nursing staff, and antibiotic orders that included indication, dose, and duration. However, stewardship documents identified that the facility lacked a defined diagnostic algorithm, Point Click Care charting was not aligned with McGeer's or LOBES criteria, reflex urine cultures were being performed without indication, and UTI antibiotic courses were not consistently reassessed at 72 hours. Record review showed that on 4/1/26, a resident reported increased fatigue and the provider ordered a CBC, CMP, and UA, but the IP determined the resident did not meet McGeer's or LOBES criteria when the labs and UA were ordered. On 6/30/26, another resident had a change in mental status, was assessed with no signs or symptoms of infection identified, had a UA performed, and was prescribed Cipro 500 mg twice daily for 7 days even though the IP determined the resident did not meet criteria. The report also stated that staff would contact the provider to discontinue the order because the resident did not have urinary symptoms and the altered mental status resolved prior to antibiotic therapy initiation. On 7/22/26, the IP confirmed infection control screening was not conducted for either resident and stated there was no real process in place, while also confirming the expectation was to use McGeer's and LOBES criteria before reporting symptoms, sending cultures, and initiating antibiotics.
Failure to Document Rationale for Ongoing Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to implement antibiotic stewardship practices for one resident who was reviewed for antibiotic use. The facility’s Antibiotic Stewardship Policy dated 3/2018 instructed staff to collaborate with providers regarding the resident’s clinical status and current treatment and to document the clinical rationale supporting antibiotic use. Resident 5 was readmitted in 1/2025 with diagnoses including UTI, and the 5/24/26 Annual MDS indicated the resident was cognitively intact and taking an antibiotic. Hospital clinical records dated 1/6/25 showed the resident was discharged on low-dose chronic suppressive therapy with Bactrim daily because of four UTIs in four months. A pharmacy recommendation dated 4/27/26 stated the pharmacist advised the prescriber that periodic assessment of prophylactic antimicrobial therapy was needed to minimize potential resistance and asked whether the antibiotic needed to continue indefinitely and for a brief risk-versus-benefit assessment to justify continuation. The prescriber marked yes to continuing the antibiotic but did not provide written justification. Review of the 7/2026 physician orders showed Bactrim DS 800-160 mg, 0.5 tablet daily, and the MAR showed it was administered daily as ordered. Staff 14 stated he was not the original prescriber and continued the medication because the hospital felt it was necessary, but he had not evaluated the ongoing use or documented justification. Staff 3 stated she was unsure why the antibiotic was ordered prophylactically and had not reviewed the need to continue daily Bactrim. Staff 2 stated she thought Staff 14 had provided justification, but no additional information was provided.
Failure to Monitor Antibiotic Use and Stewardship
Penalty
Summary
The facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use, and resistance. Review of the infection control binder on 7/20/26 showed no antibiotic tracking for correct indications, dosage, duration, resistance, or 72-hour time-outs to review cultures and verify correct antibiotics or resistance to prescribed antibiotics. The deficiency had the potential to affect all 82 residents residing in the facility. During interview on 7/22/26, the ADON stated she was new to the facility, had been hired as the infection preventionist, and had just started working on an antibiotic stewardship program. She stated she was unable to find documents from the prior infection preventionist showing that antibiotic usage had been tracked and monitored, and that she had started tracking antibiotics backwards only a few months. The IDON stated the prior employee responsible for antibiotic stewardship had left the facility and that there was no evidence of tracking antibiotic usage for correct dosage, duration, resistance, or completion of 72-hour time-outs. The facility infection prevention and control program policy dated 11/2024 stated that culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities and that antibiotic usage is evaluated and practitioners are provided feedback on reviews.
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