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F0881
F

Failure to Implement Antibiotic Stewardship Program and Timely Review of Antibiotic Use

Haverhill, Massachusetts Survey Completed on 04-24-2025

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 outlined in its policy, which requires the collection and documentation of antibiotic usage and outcome data using an approved surveillance tracking form. The policy also states that the Infection Preventionist (IP) is responsible for reviewing antibiotic utilization and identifying instances of inappropriate antibiotic use, as well as reviewing and documenting the outcomes of antibiotic therapy. However, a review of the facility's line listings for January, February, and March 2025 showed that a total of 77 antibiotics were prescribed during this period, with no documented follow-up or review with a physician or nurse practitioner after the initiation of any of these antibiotics. During an interview, the IP confirmed that there is no review for appropriateness or efficacy of antibiotics until she has time to review the monthly infection control line listings, despite acknowledging that antibiotics should be reviewed within 48-72 hours of initiation.

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