Failure to Review and Discontinue Unnecessary Antibiotic Therapy
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in a resident continuing to receive antibiotic therapy without appropriate clinical indication. Record review showed that a resident with a history of Methicillin Susceptible Staphylococcus Aureus (MSSA) infection and sepsis was prescribed Amoxicillin-Potassium Clavulanate with no documented stop date. Despite the resolution of the infection, the antibiotic was not discontinued, and there was no evidence that the indication for continued use was reviewed or confirmed by the facility's staff or consulting pharmacist. Interviews with the Infection Preventionist (IP) and the Pharmacist revealed that the ongoing need for the antibiotic was not reassessed after the initial prescription, and the resident was not included in subsequent antibiotic stewardship reviews. The IP acknowledged not seeking clarification from the infectious disease physician regarding the continued use of the antibiotic after the infection had resolved. The Pharmacist also agreed that the indication for the antibiotic should have been reviewed, but this was not done, contrary to the facility's policy and CDC guidelines.