Failure to Follow Antibiotic Stewardship Policy for UTI Treatment
Penalty
Summary
The facility failed to implement its policy on antibiotic use and change in condition for one of five sampled residents, resulting in the administration of antibiotics without meeting established criteria. A resident with diagnoses including Alzheimer's disease, dementia, and depression was admitted and later had an abnormal urinalysis. Subsequently, a physician ordered Cephalexin for a urinary tract infection, and the medication was administered for ten days. However, the resident's medical record did not document any of the required signs or symptoms of a symptomatic UTI as outlined in the facility's Infection Criteria Checklist, and there was no urinary catheter in place. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the necessary documentation of UTI signs and symptoms was not present in the resident's record. Both staff members acknowledged the importance of completing infection criteria and tracking to ensure appropriate antibiotic use and compliance with the facility's Antibiotic Stewardship Program. Review of facility policies indicated that changes in resident condition and antibiotic use should be thoroughly documented and tracked, but these procedures were not followed in this case.