Failure to Implement and Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its own policy and infection control standards. Specifically, the program did not ensure that accurate and complete information regarding signs and symptoms of infection was collected, monitored, and documented on monthly infection line listings for two of three months reviewed. The February and April infection line listings were missing critical documentation of signs and symptoms for multiple entries, including cases of cholecystitis, urinary tract infections, wound infections, osteomyelitis, cellulitis, and sepsis. In several instances, only the diagnosis or hospitalization was recorded without any supporting clinical details, such as the onset date or specific symptoms, and in one case, an antibiotic was started without any documentation of symptoms or diagnosis. For one resident with a history of Bullous Pemphigoid, the facility did not follow McGeer's Criteria, a tool used to determine if antibiotic treatment is indicated. This resident was prescribed two courses of doxycycline for cellulitis, but the documentation showed only new redness and serosanguinous drainage, without other required symptoms or evidence that McGeer's Criteria were met. There was no documentation of fever, pus, or other qualifying symptoms, and vital signs were not recorded to rule out fever. Additionally, the second course of antibiotics for this resident was not entered on the April infection control line listing, further indicating a lack of proper tracking and oversight. Interviews with facility staff, including the Administrator/Infection Preventionist and the DON, revealed that while McGeer's Criteria was the stated tool for infection assessment, there was no consistent process for documenting its use or for communicating with providers when criteria were not met. Staff could not recall specific discussions or documentation regarding the initiation of antibiotics for the resident in question, and the last completed infection screening evaluation in the EHR was from 2022. This lack of documentation and oversight resulted in incomplete tracking of antibiotic use and infection assessments.