Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to properly implement and monitor an antibiotic stewardship program, as evidenced by the lack of identification, monitoring, and review of prophylactic antibiotic use for four residents. The Infection Prevention and Control Program, dated 2019, outlined the need for an antibiotic stewardship program, including protocols and a system to monitor antibiotic use. However, the facility did not adhere to these protocols, as the Infection Control Log showed that residents received prophylactic antibiotics without signs or symptoms of infection. The consultant pharmacist's Medication Regimen Review reports did not include antibiotic usage, and the Infection Report Summary lacked data on prophylactic antibiotic use. Specific cases included residents receiving antibiotics for urinary tract infection prophylaxis without documented symptoms or appropriate diagnoses. For instance, one resident had a physician's order for an antibiotic with no end date, and another had an order for an antibiotic without a documented reason. The facility's Quality Assurance Committee meetings did not address antibiotic usage, and the Infection Preventionist acknowledged that certain diagnoses, such as urge incontinence, did not require antibiotics. The facility's administrator and director of nursing admitted that the antibiotic stewardship program was incomplete and needed improvement.