Failure to Prevent Unnecessary Concurrent Antibiotic Use
Penalty
Summary
A resident with a history of urinary tract infections (UTIs) was prescribed Bactrim for UTI prophylaxis to be administered on Mondays, Wednesdays, and Fridays, starting April 1, 2025, with no specified end date. Following a hospital admission for weakness and lack of responsiveness, the resident returned to the facility with a new order for Keflex, intended for a 7-day course, but the order was entered into the system without a stop date and was continued for 30 days. During this period, the resident continued to receive Bactrim concurrently with Keflex, despite no clinical documentation supporting the simultaneous use of both antibiotics or the extended duration of Keflex therapy. The facility's records and infection control log confirmed that both antibiotics were administered together, and there was a lack of documentation justifying this practice. The DON acknowledged that the Bactrim order should have been placed on hold while the resident was receiving Keflex and that the extended duration of Keflex was due to an error in order entry. Additionally, the DON reported being behind on tracking antibiotic use during this period, which contributed to the oversight.