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F0881
E

Failure to Implement Antibiotic Stewardship Program and Proper Surveillance

San Dimas, California Survey Completed on 06-12-2025

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 implement its antibiotic stewardship program for two of five sampled residents, resulting in the improper monitoring and documentation of antibiotic use. For one resident with vascular dementia and generalized weakness, a change in condition was noted with greenish vaginal discharge but no pain, discomfort, or fever. Despite these findings and a urine culture report indicating that antibiotic therapy was not recommended without localized urinary tract symptoms, the resident was prescribed and administered Diflucan. The Infection Control Nurse (ICN) acknowledged that the wrong surveillance form was used and that the appropriate McGreer's UTI criteria should have been applied to determine the necessity of antibiotics, but this review was missed for the month in question. Another resident with neuralgia and generalized weakness was prescribed Azithromycin for a tooth infection. The ICN stated that the incorrect antibiotic surveillance form was used for this resident as well, and the proper screening for skin/mucosal infection was not completed. The ICN did not follow up to verify if the correct antibiotic screening was performed, resulting in the resident receiving antibiotics without confirmation that the criteria for a true infection were met. Facility policy required the use of approved antibiotic surveillance tracking forms and regular review of antibiotic usage patterns by the leadership team. The Infection Preventionist was responsible for implementing the infection prevention and control program, including the collection and review of antibiotic use data. However, these protocols were not followed, and the required documentation and monitoring were not completed for the residents in question.

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