Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its own policies and regulatory standards. Although the facility had established protocols and policies for antibiotic stewardship, including the use of infection screening evaluations, laboratory testing, and monitoring of antibiotic use, these were not followed in practice. A review of infection surveillance records for a one-year period revealed that there were no documented culture results, no data on pathogens, and no evidence of review to determine if antibiotic prescribing met established criteria. During an interview, the Infection Preventionist confirmed that the facility had not identified, tracked, or analyzed organisms found through laboratory testing to assess whether antibiotic use was appropriate or met treatment criteria. This lack of monitoring and documentation meant that the facility could not ensure antibiotics were being used according to best practices, as outlined in their own policies and procedures. The deficiency had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.