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F0881
D

Failure to Follow Antibiotic Stewardship Protocols

Pasadena, California Survey Completed on 06-05-2025

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 follow its antibiotic stewardship program protocols for prescribing antibiotics to a resident prior to the administration of antibiotic therapy. Specifically, a review of the resident's records showed that the resident was prescribed and administered meropenem IV for pneumonia, despite only meeting one of the three required criteria for antibiotic therapy as documented on the surveillance data collection form. There was no documentation that the physician was notified about the resident not meeting all required criteria before the antibiotic was started. The resident involved had a history of pneumonia, sepsis, urinary tract infection, and ESBL resistance, and was severely cognitively impaired and dependent on staff for daily activities. The Infection Preventionist Nurse confirmed during interview and record review that all three criteria must be met for antibiotic therapy to be initiated, and acknowledged the lack of documentation regarding physician notification. The facility's policy required the Infection Preventionist Nurse to review infection control surveillance forms to determine if the infection met the associated criteria, which was not followed in this case.

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