Failure to Monitor and Document Antibiotic Use and Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for two residents by not adequately monitoring antibiotic use, side effects, or adverse reactions, and by failing to maintain complete infection control surveillance records. For one resident, who was admitted with multiple complex diagnoses including seizure disorder, traumatic brain injury, respiratory failure with tracheostomy, and was in a vegetative state, there was a documented fever and increased secretions, leading to the initiation of intravenous antibiotics (Zosyn and Vancomycin). Despite care plan interventions requiring observation for adverse reactions, there was no documentation in the nurses' notes of monitoring for antibiotic use or adverse reactions during the course of treatment. Interviews with facility staff, including the MDS nurse, Infection Preventionist, and pharmacist, confirmed that the expectation was for nurses to monitor and document antibiotic use and any side effects or adverse reactions every shift. However, this monitoring and documentation did not occur as required. The pharmacist also relied on these notes for their own monitoring, further highlighting the gap in the process. For another resident, who was also in a vegetative state and dependent on staff for all activities of daily living, the facility failed to complete the Infection Control Log related to antibiotic use for a wound infection. Key information such as date of admission, signs and symptoms, organism, and date infection resolved were missing from the log. Staff interviews confirmed that the log was incomplete and that the responsibility for documentation was not consistently followed. The facility's policy required antibiotic surveillance as part of its stewardship program, but this was not carried out as documented.