Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics. Upon admission from an emergency department, a resident with a history of epilepsy was prescribed Cephalexin 500 mg for a urinary tract infection (UTI) based on hospital orders. The facility's policy requires that antibiotic use be guided by its antibiotic stewardship program, including review of lab results and clinical status to determine the necessity of continued antibiotic therapy. Despite this, the resident received 25 doses of Cephalexin over several days without documented clinical signs or symptoms of a UTI, such as dysuria, fever, urinary urgency, suprapubic pain, increased incontinence, or hematuria. Laboratory results during this period showed no significant bacterial growth in the urine culture, and although the urinalysis indicated an elevated white blood cell count, there was no clinical documentation correlating this finding with active infection. Staff interviews confirmed the absence of a documented clinical rationale for the continued use of Cephalexin. The Nursing Home Administrator acknowledged the lack of supporting documentation and the facility's responsibility to ensure residents are not administered unnecessary antibiotics.