Failure to Consistently Monitor and Ensure Appropriate Antibiotic Use
Penalty
Summary
The facility failed to maintain a consistent system for monitoring and ensuring appropriate antibiotic use for its residents. Review of infection surveillance records showed that antibiotics were prescribed in multiple cases without meeting established criteria, such as treating urinary tract infections (UTIs) without documented signs or symptoms of infection and without laboratory confirmation. During an interview, the Infection Control Preventionist (ICP) confirmed that McGeer's Criteria was the standard used, but acknowledged that antibiotics were sometimes prescribed based only on urinalysis (UA) results, without obtaining a culture and sensitivity (C&S) to confirm infection or guide antibiotic selection. The ICP also indicated ongoing efforts to educate nursing staff to request C&S testing, but could not explain how appropriate antibiotic selection was ensured when only a UA was performed. Facility policy required review of clinical signs, symptoms, and laboratory reports to determine the need for antibiotics, but this protocol was not consistently followed.
Plan Of Correction
1.) All Residents have the potential to be affected. 2.) A one-time audit was completed on ABT within the last 14 days to ensure they meet McGeer's criteria or have a risk versus benefits completed. The licensed nurses and providers were re-educated on McGeer's criteria. 3.) System change: Mon-Friday during the clinical meeting the ICP/Designee will review ABT to ensure they are meeting McGeer's criteria. 4.) DON/Designee will review 5 ABT weekly x 12 weeks then monthly x 3 months to ensure McGeer's criteria is met or risk versus benefit is obtained. Any non-adherence will result in 1:1 education. All audits will be brought to QA committee for review and further recommendations. The Director of Nursing is responsible for ongoing sustained compliance.