Failure to Follow Antibiotic Stewardship Protocols for Infection Criteria
Penalty
Summary
The facility failed to accurately monitor and address the use of antibiotics for a resident when the resident's symptoms did not meet the McGeer's criteria or Loeb minimum criteria for a true infection. According to the facility's policy, the Antibiotic Stewardship Program is intended to optimize infection treatment and reduce adverse events by using established criteria to define infections and guide antibiotic use. However, documentation for one resident showed that antibiotics were prescribed despite the resident being afebrile and lacking purulent sputum, which did not meet the required criteria for initiating antibiotic therapy. The Infection Surveillance Monthly Report and Infection Screening Evaluation did not clearly indicate whether the resident's symptoms met the McGeer's or Loeb criteria, and the medical record lacked evidence of fever or increased sputum at the time antibiotics were ordered. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the resident's symptoms did not meet the criteria for a true infection and that the physician should have been accurately notified of this when the antibiotic was ordered. The IP acknowledged that the facility's process was not followed, as the resident's symptoms were not properly evaluated against the McGeer's criteria before antibiotics were administered. This failure to adhere to the facility's antibiotic stewardship protocols resulted in the use of antibiotics without sufficient clinical justification as outlined in the facility's own policies.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 89 was affected by this deficient practice. On 7/18/2025, DON provided 1:1 education to IP nurses about facility P&P for antibiotic stewardship program, in particular following the McGeer's criteria and Loeb minimum criteria and notifying primary physician of resident's signs and symptoms for appropriate use of antibiotic medication. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents were potentially affected by this deficient practice. On 8/4/2025, DON and IP nurse reviewed residents in the last 30 days who received antibiotic and making sure McGeer's and Loeb criteria was followed and verified with primary physician and no other issue was noted. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility P&P for Antibiotic Stewardship program and identifying signs and symptoms in line with McGeer's Criteria and Loeb minimum criteria and verifying with primary physician for appropriate usage of antibiotic medication, especially if resident does not meet McGeer's or Loeb criteria. DON emphasize on documenting in resident's medical record if primary physician insisted on continuing the Antibiotic even if resident infection does not meet McGeer's or Loeb Criteria for unnecessary use of Antibiotic. Resident plan of care will also be updated. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON and IP nurse or designee will oversee this process. If a resident developed signs and symptoms of possible infection, RN supervisor or charge nurse will notify primary care physician (PCP) for the COC. If PCP ordered antibiotic, RN supervisor or charge nurse will initiate appropriate use of antibiotic and might suggest to PCP for additional testing, such as labs before initiating antibiotic use. If PCP insisted to start antibiotic, RN supervisor or charge nurse will document in resident medical records and initiate McGeer's criteria or Loeb minimum criteria and reported to IP nurse. IP nurse will re-evaluate Antibiotic use and if McGeer's Criteria or Loeb criteria was not met, IP nurse would verify with primary physician for antibiotic use and suggest antibiotic timeout. IP nurse would update plan of care based on PCP order. IP Nurse will report antibiotic use monthly to infection control committee and any PCP not complaint with McGeer's and Loeb Criteria will be discuss with Medical Director. Medical record will audit all new antibiotic order for compliance to antibiotic stewardship program and report to DON x 3 months. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025.