Failure to Monitor and Document Antibiotic Use per Stewardship Protocols
Penalty
Summary
The facility failed to follow its own antibiotic stewardship program and standards of practice for monitoring antibiotic use, as evidenced by the lack of verification that infection criteria were met and insufficient monitoring of symptoms and treatment effectiveness for several residents started on antibiotics. The policy required nursing staff to assess residents suspected of infection, verify infection criteria (such as McGeer's Criteria), and document both the initiation and ongoing monitoring of antibiotic therapy, including an antibiotic timeout within 48-72 hours. However, for multiple residents, there was no documentation that these steps were followed. One resident with a history of cystitis and chronic kidney disease was started on antibiotics for urinary symptoms, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of treatment during and after the antibiotic course. Another resident with encephalopathy and failure to thrive was prescribed antibiotics for a UTI, but there was no documentation of infection criteria assessment or monitoring of symptoms and treatment response. Similarly, a resident with multiple sclerosis and overactive bladder was started on antibiotics for a UTI based on staff observations and lab results, but again, there was no documentation of infection criteria review or monitoring of symptoms before or after starting antibiotics. Additionally, a resident with chronic obstructive pulmonary disease and paroxysmal atrial fibrillation was treated for pneumonia after a chest x-ray, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of antibiotic treatment. Interviews with facility staff confirmed that while McGeer's Criteria were referenced, there was no documentation of their use, and no evidence of required monitoring or assessment was found in the records. The facility's failure to document these critical steps led to the deficiency.