Failure to Implement Antibiotic Stewardship and Ensure Physician Notification
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as outlined in its policies and procedures. Specifically, the facility did not ensure that physicians were informed when residents received antibiotics without meeting McGeer's Criteria for true infection, as documented in the May and June 2025 surveillance logs. Two residents received antibiotics without meeting the criteria, and there was no documentation that their physicians were notified. Additionally, for two other residents, the facility did not follow up on urine laboratory results or communicate findings to the prescribers, nor was there documentation of physician notification or follow-up regarding repeat cultures or pending results. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that surveillance logs and line listings for antibiotic use and infections were missing for several months, and the current IP only began documenting antibiotic use as of mid-May 2025. The IP and DON confirmed the lack of documentation and inability to verify that appropriate notifications and follow-ups occurred. The facility's failure to maintain required records and ensure communication with physicians regarding antibiotic use and laboratory results led to the identified deficiency.