Failure to Monitor and Justify Antibiotic Use
Penalty
Summary
A deficiency was identified when a resident was prescribed and administered Azithromycin without a documented clinical indication for a specific infection. The resident, who was admitted with multiple chronic conditions including respiratory failure, COPD, hypertensive heart disease, and chronic kidney disease with heart failure, was observed to be alert, oriented, and without any signs or symptoms of infection. Medical records and the comprehensive care plan referenced antibiotic therapy for infection but did not specify the type of infection being treated. Laboratory results, including white blood cell counts and daily body temperatures, were within normal limits, and there was no evidence of fever or infection. Further review revealed that the facility's antibiotic stewardship protocols were not followed. The Infection Preventionist was unable to provide a clear reason for the antibiotic prescription and noted that the required McGeer/Antibiotic monitoring form was either incomplete or not properly signed. The form that was eventually presented indicated that the resident did not meet criteria for infection. The facility's policy mandates the use of McGeer's Criteria and proper documentation for antibiotic use, but these procedures were not adhered to in this case.