Failure to Discontinue Prophylactic Antibiotic During Active Infection Treatment
Summary
The facility failed to promote antibiotic stewardship by not ensuring appropriate use of antibiotic therapy and not providing written rationale from the provider when an antibiotic was used outside of established criteria. Specifically, a resident with a history of recurrent urinary tract infections and moderate cognitive impairment was prescribed Cephalexin as a prophylactic antibiotic, despite the facility's policy discouraging prophylactic antibiotic use. The resident had an indwelling catheter removed in March and had frequent bowel incontinence, with a care plan in place to assess and prevent recurrent UTIs. When the resident developed symptoms and a urine culture indicated the presence of pseudomonas aeruginosa, a new antibiotic, Cefdinir, was ordered to treat the active infection. However, the original prophylactic Cephalexin order was not discontinued, resulting in the resident receiving two cephalosporin antibiotics simultaneously. Nursing staff recognized the issue after the fact but did not immediately notify the provider or discontinue the prophylactic antibiotic. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's concurrent antibiotic orders. The DON, who oversaw the antibiotic stewardship program, was unaware of the prophylactic Cephalexin order and confirmed it should have been discontinued when the new antibiotic was started. The nurse practitioner who prescribed the antibiotics also stated she was not reminded of the ongoing prophylactic order and emphasized the risks of unnecessary dual antibiotic therapy. The facility's policy required antibiotics to be prescribed only for active infections or suspected sepsis, based on clinical criteria and culture results.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Implement Antibiotic Stewardship and Track UTI Trends: The facility failed to review UTIs using established infection criteria before antibiotics were given and failed to track, trend, or analyze infection data. The IP only logged antibiotic orders, did not review resident symptoms or determine whether infection criteria were met, and was unsure of the UTI criteria. Infection logs showed numerous recurrent UTIs, including a recurring E. coli pattern, but there was no documentation of analysis, source identification, or staff education on prevention measures such as perineal care, catheter care, or hydration.
The facility failed to maintain an antibiotic stewardship process and did not complete an ATO for a resident treated for a UTI. The resident had behaviors, incontinence, a fall, and cloudy urine, was started on Cipro, and progress notes showed ongoing review of symptoms and culture results, but staff confirmed there was no consistent ATO process or form in use and the antibiotic tracking forms were left blank for ATO completion.
Incomplete Antibiotic Stewardship Surveillance Log: The DSD/IP did not ensure the antibiotic surveillance log was complete and accurate because urine C&S results for residents treated for UTI were not documented or followed up in the log. The DSD/IP stated she did not have access to the lab system and was unsure whether the ordered antibiotics were appropriate without knowing if the bacteria were susceptible or resistant. The MDSC, LVN, and DON all stated C&S results were important for confirming the correct antibiotic and that the IP was responsible for tracking and updating these results.
Failure to Monitor Antibiotic Side Effects The facility did not document required monitoring for adverse effects for two residents receiving antibiotics. One resident received ciprofloxacin for a UTI, and although the care plan called for observation of side effects, the MDSC could not find documentation that monitoring occurred. Another resident received cephalexin, and progress notes did not show the required every-shift monitoring for adverse reactions during the antibiotic course. Staff interviews confirmed that monitoring and documentation were expected for residents on antibiotic therapy.
Failure to perform infection surveillance for a resident receiving long-term Neomycin for cirrhosis. The resident was severely cognitively impaired and dependent on staff for ADLs, and the chart showed an order for Neomycin 500 mg PO TID with a care plan that included the antibiotic. The IP stated an infection surveillance form should be created for antibiotic use to verify McGeer’s and Loeb’s criteria, but no surveillance form was completed for this long-term antibiotic, and the DON stated every resident on an antibiotic should have a surveillance assessment.
The facility failed to follow its antibiotic stewardship program for a resident who was started on Macrobid for urinary frequency after the family reported symptoms and the MD ordered urine testing. Lab results later showed urogenital flora, and the IP stated the antibiotic use did not meet McGeer’s Criteria and should have been discontinued. Review of the ATB log also showed multiple residents had antibiotic use that did not meet McGeer’s criteria, and staff stated nurses did not use criteria when communicating suspected infections or receiving antibiotic orders.
Failure to Implement Antibiotic Stewardship and Track UTI Trends
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program and failed to review urinary tract infections using established infection criteria before antibiotic treatment. Based on staff interview, record review, and facility policy review, the infection preventionist only reviewed physician antibiotic orders and entered them into the monthly infection tracking log, without reviewing resident symptoms or determining whether infection criteria were met before treatment. The infection preventionist stated she was unsure what criteria were used to determine whether residents met the requirements for a UTI diagnosis and did not track or trend infections, evaluate recurring infection patterns, or analyze antibiotic utilization. Review of the facility's urinary infection tracking logs from February 2026 through April 2026 identified 54 UTI episodes, excluding residents admitted with infections and duplicate entries for the same active infection. Multiple residents had recurrent UTIs, and the logs showed a recurring pattern of E. coli in urine cultures, but there was no documentation that the facility analyzed the infections, identified contributing factors or the source, or implemented interventions to reduce infections. The May 2026 infection control log was not completed as of 6/2/26, and the infection preventionist stated she was usually about one month behind in documentation. She also stated she was unaware a resident was on contact precautions for ESBL in urine and confirmed she had not provided staff education regarding perineal care, catheter care, hydration, or other measures to reduce UTI occurrence.
Failure to Monitor Antibiotic Use and Complete Antibiotic Timeouts
Penalty
Summary
The facility failed to perform antibiotic stewardship by not maintaining a system to monitor antibiotic use and reduce antibiotic resistance, and it failed to follow its own antibiotic stewardship policy by not completing an antibiotic timeout (ATO) for one sampled resident. The current CDC guidance reviewed by surveyors states that residents suspected of infection should be evaluated for clinical signs and symptoms and then comprehensively reviewed within 48-72 hours after starting an antibiotic to assess effectiveness using current symptoms and laboratory results. The facility’s Resident Antibiotic Tracking forms from February 2026 through May 2026 had the section for whether an ATO was performed left blank each month. For the sampled resident, behaviors, incontinence, a fall, and cloudy urine were documented, and a urinalysis and culture identified a UTI. The resident was started on Ciprofloxacin 500 mg by mouth twice daily for 7 days, and the antibiotic course was completed with symptoms later noted as resolved. Review of progress notes showed documentation around the infection, the fall, decreased intake, sleepiness, and the abnormal culture, but there was no indication that an ATO was completed within 48-72 hours of starting the antibiotic. Staff interviews confirmed there was no consistent ATO process or form in use, and the DON stated staff were expected to follow the antibiotic stewardship policy and complete ATOs.
Incomplete Antibiotic Stewardship Surveillance Log
Penalty
Summary
The facility failed to promote and implement an antibiotic stewardship and surveillance program because the Infection Preventionist did not ensure the antibiotic surveillance log was complete and accurate to identify, track, and monitor resident antibiotic use. During a concurrent interview and record review, the DSD/IP stated she started as IP in August 2025 and shared the IP role with the MDSC. She stated that part of her responsibility was monitoring infections and keeping track of logs, but when reviewing the antibiotic surveillance log she did not have a record of urine analysis culture and sensitivity results for residents who were ordered antibiotics for urinary bladder infections. The DSD/IP stated she did not have access to the laboratory system to print the results and was not sure whether the antibiotics ordered were appropriate without knowing whether the bacteria were susceptible or resistant to the medication. She also stated she was not sure why the result was needed because residents were already ordered antibiotic medications. During interview, LVN 2 stated primary doctors usually order urine tests with C&S before antibiotics for residents with signs of bladder infections, and that it was the IP’s responsibility to update the primary doctor with the urine test results once completed. LVN 2 also stated all licensed nurses have access to lab results and was not sure why the DSD/IP did not have access. The MDSC stated she also shared the IP position, but the DSD/IP was responsible for the antibiotic surveillance log. The MDSC stated C&S results were important to make sure the correct antibiotic was ordered and that infection could re-occur if bacteria were resistant to the prescribed antibiotic. The DON stated the DSD/IP was responsible for ensuring the antibiotic surveillance log was accurate and complete so the antibiotic ordered was appropriate to treat the bacteria causing the infection, and that the DSD/IP should have followed up on C&S results and updated the primary doctor. The facility policy for the Antibiotic Stewardship Program stated the IP maintains documentation related to antibiotic use tracking and monitoring, and the CDC reference stated nursing homes should review medical records for new antibiotic starts to determine whether clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices.
Failure to Monitor Adverse Effects During Antibiotic Therapy
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not documenting monitoring for adverse effects for two residents receiving antibiotic therapy. One resident was admitted with diagnoses including UTI, neuromuscular dysfunction of the bladder, and a punctured abdominal wall wound. The resident’s H&P indicated capacity to understand and make decisions, and the MDS showed the resident could make self-understood and understand others, with moderate impaired cognition and use of a high-risk drug class antibiotic. For this resident, the OSR showed an order for Ciprofloxacin HCl 500 mg by mouth every 12 hours for UTI for 7 days. The care plan, initiated for antibiotic therapy related to UTI and risk for adverse reaction, included an intervention to observe for side effects or adverse reactions and call the MD once noted. During interview and record review, the MDSC stated the chart contained the ciprofloxacin order and care plan, but he could not find documentation showing monitoring for adverse effects of the medication. The MDSC stated there was no documentation to support that the monitoring was being done, and the DON stated the resident should have had monitoring for adverse effects to prevent harmful effects and allow physician intervention. A second resident was admitted with diagnoses including visual loss in both eyes, lack of coordination, and protein-calorie malnutrition. The H&P noted cognitive impairment, and the MDS showed severely impaired cognition, inability to understand and make needs known, and substantial to total assistance with ADLs. The resident received cephalexin by telephone order, 7500 mg, one tablet by mouth every 6 hours for 7 administrations until finished. The care plan directed staff to administer medication as ordered, monitor vital signs, and observe for side effects every shift, but progress notes from the listed shifts did not document monitoring for adverse side effects during the antibiotic course. Staff interviews confirmed that licensed nurses were expected to monitor residents on antibiotics every shift and document it in the progress notes, and the DON stated this monitoring was important so staff could detect adverse effects and notify the physician.
Failure to Perform Infection Surveillance for Long-Term Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program when it did not conduct infection surveillance for a resident who was prescribed long-term Neomycin Sulfate 500 mg by mouth three times a day for cirrhosis. Resident 4 was admitted with diagnoses including liver cirrhosis and, on the MDS, was documented as severely cognitively impaired and dependent on staff for showering, dressing, and personal hygiene. The physician’s order for Neomycin was dated 3/27/2026, and the care plan for liver cirrhosis, initiated 2/28/2026, included the antibiotic as an intervention. During a concurrent interview and record review, the Infection Preventionist stated that when a resident is prescribed an antibiotic, an infection surveillance form should be created to ensure McGeer’s and Loeb’s criteria are met. She stated she documents on the infection surveillance form for new antibiotics within 48 hours of admission and checks whether the resident’s signs and symptoms meet those criteria, and communicates with the doctor if they do not. She also stated Resident 4 was on Neomycin long term to prevent bacterial growth and ammonia accumulation, but there was no infection surveillance form for this use. The Infection Preventionist stated that there should be documentation somewhere regarding the rationale for the long-term use of Neomycin and that the pharmacy was obtaining the rationale. The DON stated every resident prescribed an antibiotic should have a surveillance assessment to monitor antibiotic use and effectiveness and to ensure the resident is not at risk for more infection. The facility policy for Antibiotic Stewardship Program stated the IP is responsible for infection surveillance and MDRO tracking, and the Antibiotic Time-Out policy stated the licensed nurse will contact the prescribing physician 48-72 hours after initiation of antibiotics to review the need for the antibiotic, the correct antibiotic, dose, route, and duration.
Failure to Follow Antibiotic Stewardship Criteria
Penalty
Summary
The facility failed to implement its antibiotic use protocols for one sampled resident who was prescribed Macrobid 100 mg twice daily for 5 days for a suspected UTI after the resident’s daughter reported frequent urination throughout the night and the physician was notified. The nurse’s note documented the report of urinary frequency, and urine testing was ordered. Lab results later showed that the urine culture collected on 4/11/26 and again on 4/17/26 final result indicated urogenital flora was isolated. During review of the facility’s monthly antibiotic stewardship/surveillance log, the Infection Preventionist stated the resident’s Macrobid use for UTI did not meet McGeer’s Criteria. She also stated nurses do not have or use criteria when receiving antibiotic orders, that McGeer criteria are used after residents are started on antibiotics, and that the resident’s antibiotic order should have been discontinued when the lab results showed urogenital flora. The review further found that multiple residents on the April 2026 antibiotic log had antibiotic use that did not meet McGeer’s criteria, and the facility’s policy stated antibiotics were to be prescribed and administered under the guidance of the antibiotic stewardship program.
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