Failure to Complete Antibiotic Surveillance Documentation
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for one of three sampled residents by not completing an Infection Surveillance Outcome form for a resident who was prescribed multiple antibiotics. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, skin cancer, and recent scalp surgery, and was cognitively intact and able to make decisions. Upon review, it was found that the resident was receiving Vancomycin and Meropenem for a brain abscess, as well as Erythromycin ointment and Bacitracin Zinc ointment for other conditions. However, the Infection Preventionist did not review or document the use of Vancomycin and Meropenem on the required surveillance form. Interviews with facility staff confirmed that the Infection Preventionist was responsible for completing the Infection Surveillance Outcome form for all residents on antibiotics, and that this process was not followed for the resident in question. The facility's policy required that all antibiotic usage and outcomes be documented and reviewed as part of the Antibiotic Stewardship Program, but this was not done for the antibiotics prescribed to the resident. This lapse was identified through interviews and record reviews conducted by surveyors.