Failure to Discontinue Prophylactic Antibiotic During Active Infection Treatment
Penalty
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.