Failure to Monitor and Document Antibiotic Use in Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program with protocols and a system to monitor antibiotic use. The facility's policy assigned the Infection Preventionist (IP) responsibility for monitoring, investigating, and controlling infections, as well as tracking infection incidence rates and reviewing this information quarterly with the interdisciplinary team and medical director. However, review of infection surveillance logs revealed missing documentation, including incomplete records of symptom onset dates, culture/test types and results, antibiotic treatment parameters (such as antibiotic selection and start/stop dates), and infection resolution dates and times. During an interview, the Infection Preventionist (RN) stated that antibiotic tracking was based on monthly reports received from an external pharmacy provider, which were reviewed approximately two weeks after antibiotics were started. The RN was unable to describe a process for tracking infections, monitoring antibiotic selection, or ensuring appropriate antibiotic use, and deferred these decisions to the prescribing physician. The RN also confirmed that no standardized criteria, such as McGeer's or Loeb's, were being used to determine the need for antibiotics or to monitor their appropriateness, and was unfamiliar with these guidelines until referenced by the surveyor.