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F0881
D

Failure to Implement Antibiotic Stewardship Program

Elmhurst, Illinois Survey Completed on 05-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its antibiotic stewardship program as required, resulting in incomplete monitoring and documentation of antibiotic use for two residents. For one resident who was started on Ceftriaxone for a urinary tract infection (UTI), the Infection Preventionist (IP) Nurse identified that the McGeer Criteria assessment form was not completed to determine if the prescribed antibiotic was appropriate. Additionally, the urinalysis specimen was not analyzed for sensitivity as ordered, and the assessment form lacked documentation to confirm a review of the antibiotic's appropriateness. The resident's urinalysis was collected and reported without sensitivity analysis, and the antibiotic order remained active without proper review. For another resident receiving both Vancomycin and Meropenem, the IP Nurse was unsure of the indication for Vancomycin and noted that the McGeer assessment form was only initiated for Meropenem, not Vancomycin. The form for Meropenem was incomplete and did not clarify the reason for its use, as there was confusion regarding whether it was prescribed for MRSA in the blood, urine, or both. The facility's policy requires documentation of dose, route, duration, and indication, as well as reassessment of antibiotic use after three days, but these steps were not followed for the residents reviewed.

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