Failure to Complete Antibiotic Surveillance Forms Prior to Administration
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program protocol by not completing the required surveillance data collection forms prior to administering antibiotic therapy to three residents. For each of these residents, antibiotics were prescribed and administered without the documented assessment to determine if the criteria for antibiotic use were met, as required by facility policy. The Infection Preventionist Nurse (IPN) confirmed in interviews that the surveillance data collection forms were not completed for any of the three residents before antibiotics were given. One resident was readmitted with diagnoses including sepsis and contact dermatitis and was prescribed Cephalexin for a urinary tract infection. Another resident, admitted with immune system disorder and malnutrition, received Sulfamethoxazole-Trimethoprim for a left buttock ulcer secondary to a ruptured abscess. The third resident, admitted with MRSA and malnutrition, was prescribed Ciprofloxacin for a urinary tract infection. In each case, the Minimum Data Set (MDS) assessments indicated varying levels of cognitive and physical impairment, and the physician orders for antibiotics were documented in the residents' records. Interviews with the IPN and the Director of Nursing (DON) confirmed that the surveillance data collection forms, which are intended to evaluate the necessity of antibiotic use and prevent antibiotic resistance, were not completed as required by the facility's policies. The facility's policies specify that the IPN is responsible for collecting and analyzing infection surveillance data and ensuring adherence to antibiotic stewardship processes, including the completion of surveillance forms prior to antibiotic administration.