Failure to Monitor and Review Antibiotic Use for Multiple Residents
Penalty
Summary
The facility failed to identify, monitor, and review antibiotic use for all five residents reviewed for antibiotic stewardship, as required by their Infection Control and Antibiotic Stewardship policies. The policies specify that the Infection Control Committee is responsible for surveillance, review, and analysis of infections, as well as maintaining a system for reporting and evaluating antibiotic use. However, the facility's Infection Tracking Logs for multiple months did not include required information such as the antibiotics administered, their indications for use, or the results of relevant cultures and laboratory tests for several residents who were receiving antibiotics or antifungals. For example, one resident was on a maintenance dose of Macrodantin for a history of urinary tract infections without a documented stop date, and this was not tracked in the Infection Tracking Log or evaluated by the pharmacist. Another resident received Macrobid prophylactically and later multiple courses of Levofloxacin for urinary tract infections, but the logs did not document the antibiotics, their indications, or the results of diagnostic tests. Additional residents received various antibiotics and antifungals for conditions such as cough, skin eruptions, pneumonia, and cystitis, but the facility failed to document these treatments and their appropriateness in both the Infection Tracking Log and the Pharmacist's Summary of Recommendations. Interviews with facility staff confirmed that ongoing monitoring of residents on prophylactic antibiotics was not performed after initial initiation, and that the tracking system was incomplete and inaccurate. The Assistant DON/Infection Preventionist acknowledged that the logs did not track culture or test results, were not comprehensive, and that the pharmacist's reviews were not inclusive of all antibiotic or antifungal use. The Administrator also stated that the facility struggled with entering and ensuring the accuracy of required infection information in the new tracking system.