Failure to Implement and Document Antibiotic Stewardship for New Admissions and Community-Prescribed Antibiotics
Penalty
Summary
The facility failed to follow its established Antibiotic Stewardship Program (ASP) for newly admitted residents or those prescribed antibiotics by community providers over a three-month period. According to the facility's policy, the ASP should include the use of McGeer Criteria to determine the appropriateness of antibiotic use. However, review of the Monthly Infection Surveillance Logs for January, February, and March 2025 revealed that for a significant number of residents who received antibiotics for community-acquired infections, there was either no documentation or incomplete documentation regarding whether McGeer's minimum criteria were met prior to antibiotic administration. During interviews, the Infection Preventionist acknowledged that the ASP process was not applied to new admissions or residents prescribed antibiotics by outside providers, under the assumption that hospitals ensured compliance with McGeer Criteria. This lack of implementation and documentation was observed for multiple residents across the reviewed months, with numerous instances where the required criteria were not addressed or recorded as not applicable.