Failure to Accurately Document Antibiotic Use in Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for one resident by not accurately documenting antibiotic use in the Antibiotic Log. A resident was admitted with multiple diagnoses, including low back pain, history of falling, and hypertension. The resident was diagnosed with a urinary tract infection (UTI) and initially prescribed ciprofloxacin. The order for ciprofloxacin was discontinued the next day after urine culture and sensitivity results indicated resistance, and the antibiotic was changed to Keflex. However, the Antibiotic Log incorrectly showed ciprofloxacin as being administered for a full course and did not include any documentation of the Keflex prescription, including its start and completion dates. Interviews with facility staff, including the RN, Infection Preventionist (IP), and Director of Nursing (DON), confirmed that the Antibiotic Log was incomplete and not updated according to facility policy. The DON and IP acknowledged that the log should have reflected the change in antibiotics and that it is facility policy to monitor and document all antibiotic use. Review of the facility's policies further confirmed the requirement for accurate documentation and monitoring of antibiotic administration by the IP nurse.