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F0881
D

Failure to Timely Complete Infection Surveillance for Antibiotic Use

Chatsworth, California Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its antibiotic stewardship program by not conducting timely infection surveillance and not completing the required infection control reporting form after a resident was prescribed an antibiotic. Specifically, a resident with a history of osteomyelitis in the sacral and sacrococcygeal region, who was severely cognitively impaired and dependent on staff for daily activities, was admitted and later readmitted to the facility. Upon readmission, the resident was prescribed intravenous Vancomycin for an infection, and the care plan included administration of the antibiotic as ordered by the physician. According to the facility's policy, an infection surveillance form should be created within 48 to 72 hours of starting an antibiotic, using McGeer's criteria to determine if the resident meets the definition of a true infection. However, the infection surveillance form for this resident was not completed until 12 days after the antibiotic was started. The Infection Control Nurse confirmed that the resident met the criteria for infection, but the delay in completing the surveillance form meant that the physician was not promptly informed if the criteria were not met, as required by the facility's antibiotic stewardship policy.

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