Failure to Monitor and Document Antibiotic Use Prior to Administration
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship program that ensures appropriate use and monitoring of antibiotics. Specifically, for one resident, the facility did not ensure that clinical signs and symptoms of infection were identified and that culture results were obtained prior to the administration of antibiotics. The resident, who had a history of congestive heart failure, anemia, hypertension, benign prostate hyperplasia, obstructive uropathy, and asthma, was admitted with a urinary catheter and was cognitively intact. The resident was prescribed an antibiotic for a urinary tract infection (UTI) following a hospital visit, where a urinalysis indicated a UTI and a culture and sensitivity was ordered. However, there was no documentation in the resident's medical record to show that the culture and sensitivity was completed or that the results were obtained before starting antibiotic therapy. Staff interviews revealed a lack of specific monitoring or documentation for residents on antibiotics, and the infection preventionist acknowledged that the facility did not follow up with the hospital for the culture results. The director of nursing also confirmed that the facility did not receive or pursue the culture and sensitivity results, which are necessary to determine the most effective antibiotic treatment.