Failure to Use Standardized Tool for Infection Identification in Antibiotic Stewardship
Penalty
Summary
The facility failed to follow its policy for antibiotic stewardship by not utilizing a standardized tool to identify infections in residents when antibiotics were prescribed. Interviews with the Infection Preventionist Nurse revealed that while information about antibiotic use was logged into the EMR Infection Control Module, McGeer's criteria or any other standardized tool was not used to determine if a resident had an infection. The Director of Nursing confirmed that the facility does not use McGeer's criteria, citing a copyright issue, and relies solely on the EMR infection module, which does not indicate whether infection criteria are met before starting antibiotics. The Regional Nurse Consultant also acknowledged the absence of a standardized tool for infection identification in the EMR. A review of infection tracking records from November 2024 to the present showed no evidence that a standardized tool was used when residents were started on antibiotics. The facility's own Antimicrobial/Antibiotic Stewardship Program policy requires the use of McGeer Criteria or the EMR Infection Control Module for infection information collection, but the EMR module does not provide a standardized method to determine infection status. This deficiency applied to all 88 residents in the facility, as the process for monitoring and identifying infections prior to antibiotic use was not standardized as required by policy.