Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required. Record reviews showed that the Infection Preventionist's monthly antibiotic log for the period from 1/1/25 through 3/11/25 listed 13 resident infections, but the documentation was incomplete. Several columns intended to capture critical information such as bacteria type, infection site, and other relevant data were left blank. The log also lacked evidence of follow-through on antibiotic use, analysis of infection trends, identification of organisms, detection of infection clusters, and tracking of antibiotic types used. During an interview, the Administrator and DON acknowledged that infection tracking was incomplete, missing information on whether cultures were performed, culture results, organism identification, and appropriateness of antibiotic selection. The facility had a recent change in Infection Preventionist staff, with the previous person leaving abruptly and a new employee starting on the day of the interview, further contributing to the lack of an implemented ASP.