Failure to Implement Antibiotic Stewardship Program and Timely Monitoring
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not conducting timely reviews of antibiotic use and not ensuring physician re-evaluation when antibiotics were prescribed for suspected infections that did not meet established criteria. Specifically, the Infection Preventionist (IP) did not review any of the 25 antibiotic orders placed in April 2025 for appropriateness, as required by facility policy. This lapse was confirmed during a review of the facility's antibiotic report and medical records, where it was found that at least one resident received a full course of antibiotics without meeting the criteria for appropriate use. Additionally, the IP did not notify physicians to re-evaluate the antibiotic therapy for two residents who were prescribed antibiotics for suspected infections that did not meet the necessary criteria. In both cases, the residents received the full course of antibiotics as ordered, and there was no documentation of physician notification or re-evaluation. These failures were identified through interviews, medical record reviews, and facility documentation, demonstrating a lack of adherence to the facility's antibiotic stewardship protocols.