Failure to Follow Antibiotic Stewardship Protocol for UTI
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol for a resident who was prescribed an antibiotic for a suspected urinary tract infection (UTI) without meeting the McGeer Criteria. The resident, who was admitted with multiple diagnoses including nontraumatic intracranial hemorrhage, respiratory failure, hyperlipidemia, and dysphagia, was highly dependent on nursing staff for all activities of daily living and was unable to express wants or understand others. According to the Minimum Data Sheet, the resident did not attempt to move independently due to medical or safety reasons. A review of the Infection Screening Evaluation and interviews with the Infection Preventionist Nurse revealed that there was no documentation of infection symptoms, and the resident did not meet the McGeer Criteria at the time antibiotics were prescribed. Despite this, a physician's order was written for a 10-day course of Augmentin for a UTI. The facility's policy required specific clinical information to be gathered and communicated before prescribing antibiotics, but this protocol was not followed in this case.