Failure to Follow Antibiotic Stewardship Protocols for Two Residents
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program policy and procedure for two residents who were prescribed antibiotics without meeting the established criteria. One resident, admitted with type 2 diabetes, a foot ulcer, osteomyelitis, and a right foot amputation, was prescribed intravenous Piperacillin Sod-Tazobactam. Review of the resident's Infection Screening Evaluation indicated that the symptoms did not meet McGeer’s criteria for infection, and the Antibiotic Time Out form did not show that the physician was notified of this. Another resident, admitted with acute kidney failure and a urinary tract infection, was prescribed oral Ciprofloxacin. The Infection Screening Evaluation for this resident also indicated that McGeer’s criteria were not met, and the Antibiotic Time Out was not completed within the required timeframe. Interviews with the infection preventionist nurse revealed a lack of awareness regarding the antibiotic use for one resident and a failure to complete the required Antibiotic Time Out documentation. The infection preventionist nurse confirmed that the physician should be notified when criteria are not met and that this communication should be documented, but this was not done in either case. The facility’s policy states that McGeer criteria are used to define infections and that education on the antibiotic stewardship program should be provided to staff, practitioners, residents, and families, but these procedures were not followed for the two residents involved.
Plan Of Correction
F881 - Antibiotic Stewardship Program How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/29/25, the Infection Prevention Nurse (IPN) reviewed the antibiotic stewardship for Resident 43 and 154 and notified the MD. (Exhibit #30) 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: - On 6/2/25, the IPN reviewed the list of residents on antibiotics, checked if the residents met McGeer's criteria, and if the physician was notified for the antibiotic time out. (Exhibit #31) - No other resident was affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/2/25, the Director of Nursing (DON) provided one-on-one in-service to the IPN regarding the facility policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #32) - Starting on 6/17/25, the IPN provided in-service to the active licensed nurses regarding the policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #33) - Beginning on 6/17/25, the DON will review the Antibiotic Stewardship Program weekly for three months to ensure the physicians were notified if there is an antibiotic time out. (Exhibit #34) - Starting on 6/17/25, the IPN will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - The IPN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025