Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as outlined in its own policy. The Director of Nursing (DON), who also served as the infection preventionist, acknowledged that the facility was not consistently using the SBAR form based on McGeer criteria for infection surveillance, particularly for suspected urinary tract infections (UTIs). The DON admitted that staff often bypassed the required documentation of symptoms before contacting physicians, and the facility was almost always noncompliant with this process. Additionally, the DON did not monitor infections by resident location to identify potential clusters and only reviewed monthly antibiotic use reports from the contracted pharmacy, which lacked information on diagnosis or appropriateness of antibiotic use. Further review revealed that the facility did not adhere to several key components of its antibiotic stewardship policy. The DON did not complete an annual summary of antibiotic use, failed to hold antibiotic stewardship meetings, did not perform random audits of antibiotic prescriptions, and did not track at least one outcome measure associated with antibiotic use monthly. The facility also lacked an antibiogram, which is required to guide antibiotic use protocols, and did not provide annual feedback to prescribing physicians regarding their antibiotic use for residents. Documentation related to the stewardship program, such as meeting minutes and feedback reports, was not maintained as required by policy. The DON was unaware that the facility's infection rate for UTIs among long-stay residents was above state and national averages, as reported in the facility's quality measures. The facility's policies required the infection preventionist to report findings of surveillance activities, including infection rates and types, to the QAA committee, physicians, and other staff, but these activities were not being carried out as described. The facility's own assessment claimed that infections were tracked and trended, and that there were regular meetings to discuss infection control and antibiotic stewardship, but these practices were not substantiated by the DON's statements or by documentation.