Failure to Monitor and Document Long-Term Antibiotic Use
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Specifically, for two residents, the facility did not ensure that a physician's rationale for the use of long-term antibiotics was documented, nor was there evidence of ongoing monitoring or reassessment of the continued need for these antibiotics. The facility's own policy required documentation of dose, duration, and indication for each antibiotic, as well as regular reassessment and care planning, but these steps were not followed. For one resident with a history of chronic urinary tract infections and multiple physical impairments, the medical record showed a long-term order for Macrobid as prophylaxis, but the order lacked a specified duration and did not include the physician's rationale for ongoing use. There was also no documentation of monitoring or reassessment of the antibiotic's appropriateness, and the resident's care plan did not address the long-term antibiotic use. Similarly, another resident with a prosthetic knee and multiple comorbidities was prescribed doxycycline prophylactically, but again, the order lacked a duration, rationale, and evidence of monitoring or care planning related to the antibiotic. Interviews with staff revealed a lack of specific monitoring or documentation for residents on long-term antibiotics. The DON acknowledged that while initial assessments and short-term monitoring were performed, there was no ongoing monitoring or monthly reassessment for residents on chronic antibiotics, nor was there documentation of physician justification for continued use. The medical director confirmed that all residents on long-term antibiotics should have an indication, diagnosis, and ongoing monitoring, but this was not reflected in the records for the two affected residents.