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F0881
E

Failure to Track and Trend Antibiotic Use in Stewardship Program

Glendale, Arizona Survey Completed on 05-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently implement tracking and trending of their antibiotic stewardship program, as required by policy and CDC guidelines. During an interview with the Assistant Director of Nursing (ADON) and the Regional Clinical Director (RCD), it was revealed that the ADON was still in training as the Infection Preventionist (IP), with the previous IP assisting only a few hours per week. Review of the Infection Control Logs from January through April 2025 showed that while resident names, infection types, and antibiotics used were recorded, there was no evidence that this information was being trended or analyzed. Additionally, the RCD confirmed that the data regarding antibiotic use was not being recorded in real time, with the previous IP retroactively filling in the logs. The RCD acknowledged that antibiotics were not being tracked and trended during this period, which was not in accordance with company policy. The facility's Infection Prevention and Control Program Policy required a system to monitor antibiotic use, overseen by the IP, but this system was not being properly implemented.

See complete original report
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