Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program to monitor and ensure the appropriate use of antibiotics for all sampled residents. Review of infection surveillance logs from January through March 2025 revealed that antibiotics were prescribed and administered without consistent documentation of symptoms, cultures, or evidence of antibiotic time outs (ATO) to assess the appropriateness of therapy. In several cases, antibiotics were given for viral infections, such as COVID, or without clear indication, and there was no documentation of start and stop dates, symptom resolution, or follow-up on culture results. For example, one resident received antibiotics for both COVID and a urinary tract infection without documentation of symptoms or rationale, and another was treated for pneumonia without evidence of an ATO or follow-up on culture results. Interviews with facility staff, including the director of nursing (DON) and the infection preventionist (IP), revealed a lack of awareness and training regarding antibiotic stewardship practices, specifically the use of ATOs. The IP, who also served as the assistant director of nursing and had multiple other responsibilities, acknowledged missing information in the surveillance logs and not performing ATOs or following professional criteria for antibiotic appropriateness. The IP also reported being unable to provide adequate oversight of the infection control program due to time constraints and competing duties, and only documented infections that were treated with medication, omitting others. Policy review showed that while the facility had an antibiotic stewardship policy and an infection prevention and control program policy, these documents lacked specific processes for monitoring antibiotic use, communicating with prescribers, or performing ATOs. The policies did not outline criteria for determining the appropriateness of antibiotics or require documentation of key elements such as symptoms, culture results, or therapy adjustments. As a result, the facility did not have a functional system in place to ensure antibiotics were used appropriately, and staff were not adequately trained or competent in antibiotic stewardship practices.