Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive Antibiotic Stewardship Program (ASP) as required by its own policy and regulatory standards. Record review revealed that the facility's ASP policy aimed to reduce inappropriate antibiotic use and prevent antibiotic-resistant organisms, but the Infection Prevention and Control Program (IPCP) lacked essential components. Specifically, there were no written protocols for antibiotic prescribing, including documentation of indication, dosage, and duration. The facility also did not have protocols for reviewing clinical signs, symptoms, and laboratory reports to determine the necessity or adjustment of antibiotics, nor did it identify infection assessment tools. Additionally, there was no process for periodic review of antibiotic use by prescribing practitioners, no protocols to ensure appropriate antibiotic selection, and no system for providing feedback reports on antibiotic use, resistance patterns, or prescribing practices. Interviews with facility leadership, including the Administrator, Interim Director of Nursing (IDON), and Infection Preventionist (IP), confirmed the absence of ongoing monitoring documentation for antibiotic usage patterns and lack of evidence for an annual review of the ASP. The Medical Director (MD) was unaware of his responsibilities regarding the ASP and was not regularly involved in coordinating or monitoring antibiotic use. The Consultant Pharmacist (CP) conducted monthly medication regimen reviews but expected the facility to implement an ASP, indicating he could participate in the program if it were established. These actions and inactions resulted in the facility's failure to ensure a comprehensive and effective ASP, potentially affecting all residents.