Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective antibiotic stewardship program, as evidenced by incomplete and inconsistent documentation of infection events and antibiotic use. Infection control logs for February and March 2025 showed missing onset and resolution dates for most infections, incomplete information on whether infections were healthcare-associated, and lack of documentation regarding isolation requirements. Many infections, including urinary tract infections (UTIs) and respiratory infections, lacked culture results or evidence of appropriate diagnostic testing, and the logs did not consistently indicate whether infections were community-acquired or nosocomial. Additionally, the logs did not break down infections by site or report dates to the Infection Control/Performance Improvement Committee as required. Interviews with the Director of Nursing (DON) revealed that the facility did not consistently follow its own antibiotic stewardship protocols. The DON acknowledged that not all infections were cultured before antibiotics were prescribed, and that antibiotics were sometimes ordered prophylactically without clear documentation of appropriateness. The DON also confirmed that the Infection Preventionist (IP) had not been applying McGeer criteria during her tenure, and there was no evidence of follow-up or documentation regarding antibiotic use reviews with physicians or the Quality Assurance committee. The facility's process for reviewing antibiotic appropriateness upon admission or readmission was inconsistently applied, and there was no clear tracking of antibiotic utilization rates. A review of the facility's written policy on antibiotic stewardship outlined specific responsibilities for the IP, DON, and administrator, as well as protocols for laboratory testing, monitoring, and documentation. However, the observed practices did not align with these policies. Required documentation, such as action plans, assessment forms, data collection forms, and meeting minutes, was not maintained or was incomplete. Data from antibiotic stewardship monitoring activities was not consistently discussed in QAPI meetings, and there was a lack of feedback reports and records related to staff education. These deficiencies contributed to the facility's failure to implement an effective antibiotic stewardship program.