Incomplete Antibiotic Surveillance and Lack of Infection Evaluation
Penalty
Summary
The facility failed to maintain complete documentation on its Antibiotic Surveillance Log and did not evaluate the presence of infection using standardized criteria as required by its own policy. The Antibiotic Surveillance Logs for January, February, and March were incomplete, with missing information such as diagnosis for antibiotic use, ordering practitioner, documentation supporting necessity, and whether the antibiotic was ordered upon admission. For example, in January, 4 out of 11 residents lacked a diagnosis for antibiotic use, and 10 out of 11 had missing data in key columns. Similar patterns of incomplete documentation were observed in the logs for February and March. Additionally, there was no Antibiotic Surveillance Log available for April, and the staff member assigned as Infection Preventionist was not trained and unavailable for interview. The facility was unable to provide completed assessment forms that defined infections using recognized criteria such as McGeer, Loeb's Minimum, or NHSN surveillance definitions. Furthermore, there were no records of antibiotic stewardship meeting minutes or documentation of education provided to physicians, staff, residents, or families, as outlined in the facility's policy. This deficiency applied to all 52 residents in the facility, indicating a systemic failure to implement and monitor the antibiotic stewardship program as required.