Failure to Monitor and Manage Antibiotic Use per Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not adequately monitoring and managing the use of antibiotics for a resident with multiple complex medical conditions, including quadriplegia, tracheostomy, and a history of urinary tract infections (UTIs). The resident was started on Ertapenem for a suspected UTI based on a physician's order, despite the absence of clinical signs such as fever or elevated white blood cell count. Although a urinalysis and urine culture were ordered, no samples were successfully collected, and there were no laboratory reports or follow-up orders for these tests during the relevant period. Staff interviews revealed that the antibiotic was continued without confirmation of infection, and there was a lack of follow-up to obtain the necessary urine sample or to discontinue the antibiotic in the absence of supporting evidence. The Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse all acknowledged that the facility's antibiotic stewardship policy was not followed, as antibiotics were administered empirically without culture results or clear clinical indications, and appropriate communication and documentation were lacking.