Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy and procedure for three of six sampled residents. Specifically, the facility did not complete the required McGeer Criteria forms for residents who were prescribed antibiotics, as confirmed by both the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON). The McGeer Criteria forms are used to screen residents before initiating antibiotic therapy to ensure the appropriateness of antibiotic use. For each of the three residents, antibiotics were prescribed and administered for various infections, including peritonitis, abscess, MSSA infection, pseudomonas bacteremia, pneumonia, and chronic respiratory failure, without documented evidence that the stewardship protocol was followed. Record reviews showed that one resident was admitted with multiple antibiotic resistance and was prescribed Cephalexin for a knee abscess, another was treated with Amoxicillin-Clavulanate for MSSA and pseudomonas bacteremia, and a third received both Amoxicillin-Clavulanate and Doxycycline for pneumonia. Despite these prescriptions, the facility did not document the use of the McGeer Criteria to justify antibiotic therapy, as required by their policy. Interviews with facility staff confirmed that the forms were not completed and that the stewardship process was not followed for these residents.