Failure to Notify Physician of Culture Results and Inadequate Antibiotic Stewardship
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for a resident who exhibited signs of infection, including an elevated temperature and confusion. The attending physician gave a telephone order for cephalexin prior to the availability of urine culture and sensitivity results. When the urine culture later identified Proteus Mirabilis and provided susceptibility results, there was no evidence that the physician was notified of these findings. The infection preventionist stated it was the floor nurse's responsibility to inform the physician, but no documentation was provided to confirm that this occurred. As a result, the resident did not receive an antibiotic with the highest efficacy for the identified bacteria, as indicated by the culture and sensitivity report. Additionally, the facility did not follow its own policy requiring the primary care practitioner to assess the resident within 72 hours of a telephone order for antibiotics. Review of the physician's progress notes showed no documentation that the resident was evaluated for the urinary tract infection following the initial telephone order. The facility's policy on antibiotic stewardship specifically states that lab results and the current clinical situation should be communicated to the prescriber as soon as available, and that the practitioner should assess the resident within 72 hours of a telephone order, both of which were not followed in this case.