Failure to Implement Antibiotic Stewardship for UTI Management
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program regarding the use of antibiotics for a resident with multiple complex medical conditions, including dementia, diabetes, and schizoaffective disorder. The resident was admitted with symptoms suggestive of a urinary tract infection (UTI) and was subsequently sent to the emergency department for evaluation due to low blood pressure, lethargy, and blood-tinged urine. Following hospital admission and discharge, the resident was prescribed cefdinir for a UTI, and later, an order for Keflex was received but subsequently canceled in favor of continuing cefdinir. Despite these interventions, there was no evidence in the medical record of timely receipt or review of urine or blood culture results from the hospitalizations, nor documentation of urinalysis or culture and sensitivity reports for the relevant periods. Attempts to obtain culture results were delayed, with only one documented fax request several days after the initial hospitalization. When the results were finally received, both urine cultures from separate hospitalizations showed no bacterial growth. Staff interviews revealed uncertainty about the receipt of culture results and a lack of timely communication with the physician regarding the negative findings, resulting in the continued administration of antibiotics without supporting evidence of infection. This sequence of events demonstrates a failure to monitor and evaluate antibiotic use in accordance with stewardship principles.