Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy, affecting all 83 residents. The Director of Nursing (DON), who also served as the Infection Preventionist, admitted to not using McGeer's Criteria to assess infections since starting in November 2024. This oversight led to the inappropriate prescription of antibiotics, as evidenced by a resident who was prescribed antibiotics based on laboratory results without exhibiting any symptoms. The DON acknowledged that the resident's laboratory results did not meet McGeer's Criteria, indicating a failure to ensure antibiotics were necessary. Further investigation revealed that the facility's antibiotic use monitoring was incomplete. The DON only reviewed antibiotic use for residents currently residing in the facility at the time of report generation, rather than for all residents who received antibiotics each month. This resulted in inaccurate monitoring of antibiotic use, as shown by the Order Listing Reports for January, February, and March 2025, which indicated that no surveillance was completed for the prescribed anti-infectives during these months. Interviews with nursing staff, including agency RNs, revealed a lack of instruction and awareness regarding the use of McGeer's Criteria for assessing suspected infections. Several nurses were unaware of what McGeer's Criteria was or how to apply it, indicating a systemic issue in the facility's training and communication regarding infection assessment protocols. The facility's policy emphasized the importance of using McGeer's Criteria to classify infections, but this standard was not communicated effectively to the staff, leading to the deficiency.