Deficient Antibiotic Stewardship Program and Incomplete Documentation of Antibiotic Duration
Penalty
Summary
The facility failed to maintain an accurate and complete antibiotic stewardship program as required by its own policies and procedures. Specifically, the infection screening evaluation component of the antibiotic stewardship review did not include clear guidelines on how many criteria must be met to identify a true infection, nor did it provide an option to indicate when no criteria were met. Both the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed during interviews and document reviews that the evaluation lacked these essential elements, and that assessments were based on subjective judgment rather than standardized criteria. Additionally, the facility did not ensure that a resident's prescribed antibiotic therapy for hepatic encephalopathy included documentation specifying the duration of treatment, as required by the facility's antibiotic stewardship protocols. Medical record review showed that the resident was receiving rifaximin without a documented duration for the therapy, and both the IP and DON verified the absence of this information in the resident's records. This omission was found during concurrent interviews and record reviews with facility staff.