Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the Infection Preventionist (IP) not consistently following established protocols for antibiotic use and monitoring. Specifically, the IP did not communicate or provide notification to the primary medical doctor when residents' symptoms did not meet the McGeer criteria for antibiotic use. For two residents, antibiotics were prescribed and administered despite the absence of qualifying symptoms, and there was no documentation of physician notification or further guidance sought. In one case, a resident received a full course of antibiotics for a urinary tract infection (UTI) without presenting any UTI symptoms, and in another, a resident was given antibiotics for pneumonia despite lacking respiratory symptoms, with only weakness, lethargy, and a change in level of consciousness noted. Additionally, the IP failed to track antibiotic use for one resident who was prescribed Methenamine for UTI prevention, omitting this information from the antibiotic use monitoring spreadsheet. The facility's policy required the IP to review antibiotic utilization and notify providers of findings inconsistent with appropriate use, but this process was not followed. These actions and omissions resulted in antibiotics being prescribed and administered without proper indication or monitoring, as required by the facility's antibiotic stewardship protocols.