Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to develop a comprehensive system to monitor antibiotic use, as required by the stewardship program under CFR 483.80(a)(3). The review of records revealed that several residents were prescribed antibiotics without proper monitoring or follow-up testing. Specifically, resident #99 was prescribed an antibiotic without a subsequent culture and sensitivity test to confirm the appropriateness of the treatment. Additionally, residents #53, #87, and #20 were also receiving antibiotics, but their cases were not included in the facility's Control Report, which is supposed to track all antibiotic use. The Assistant Director of Nursing (ADON) and Infection Preventionist (IP) admitted to not analyzing trends in antibiotic prescribing or ensuring that all residents on antibiotics were included in the monthly Control Report. The facility's surveillance policy required tracking of all residents and their antibiotic use, but this was not adhered to. The ADON/IP also confirmed that the oversight led to residents not being part of the Control Report, which is reviewed during the facility's Quality Assurance meetings. This lack of a comprehensive monitoring system indicates a failure to adhere to the facility's stewardship commitment statement, which was signed by key personnel, including the Administrator and Medical Director.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Preventionist conducted an audit of all residents currently receiving to ensure appropriate indications, duration, and monitoring. The facility notified prescribing providers to ensure compliance with stewardship guidelines and discontinued or adjusted any orders that did not meet clinical necessity. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving have the potential to be affected. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs and LPNs) will receive education by the Preventionist on stewardship, including appropriate specimen collection, early signs of, and the risks of overuse. All Nursing staff (RNs and LPNs) will be in-service by Any Nursing staff (RNs and LPNs) not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff (RNs and LPNs) will be in-service by the ADON during their orientation. The Preventionist was educated by the Regional Nurse on regarding Stewardship and Control Policy. (c) How the corrective action(s) will be monitored to ensure the practice will not recur: The Preventionist will conduct audits of all new orders for compliance with stewardship protocols 5 days per week for 2 weeks then at least 5 weekly for two months, and monthly thereafter. Findings will be reported during the monthly QAPI meetings, and corrective actions will be implemented as needed. Compliance with the Stewardship Program will be reviewed during the facility's annual control risk assessment.