Failure to Implement Effective Antibiotic Stewardship and Monitor for Side Effects
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program, specifically lacking an adequate antibiotic stewardship program. A resident was administered Cephalexin for a personal history of urinary tract infections without documented evidence of a current infection, such as a urinalysis or urine culture. The clinical record did not indicate that appropriate diagnostic criteria, such as those outlined in the McGeer Criteria, were met prior to initiating antibiotic therapy. The resident experienced multiple episodes of diarrhea over several days, as documented by both certified nursing assistants and bowel and bladder elimination records. Despite these symptoms, there was no evidence that the resident was monitored for possible antibiotic side effects, nor was there documentation of appropriate follow-up or testing, such as sending a stool specimen for evaluation. Nursing staff were not consistently aware of the resident's symptoms, and discrepancies existed between CNA documentation and skilled nursing evaluations regarding the presence of diarrhea. Interviews with facility staff, including the Infection Preventionist, revealed concerns about the use of antibiotics as prophylaxis and the lack of adherence to established criteria for diagnosing urinary tract infections. The facility's policy required education on the relationship between antibiotic use and gastrointestinal disorders, but there was no indication that this was effectively implemented. The failure to monitor for side effects and to ensure antibiotics were prescribed only when clinically indicated contributed to the identified deficiency.