Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its antibiotic stewardship program was properly implemented and monitored, as required by policy. During a review of the program, it was found that the antibiotic surveillance tracking report, which should include data on antibiotic use, patterns, and resistance trends, was not completed or reviewed at quarterly medical staff meetings for the period of April 2023 to January 2024. Monthly antibiotic reports were also found to be incomplete, missing key information such as infection source, whether McGeer's criteria were met, and details on new prophylactic use. Quarterly reports lacked any information regarding the antibiotic stewardship program, and staff interviews confirmed that the responsibility for completing these reports was not fulfilled during the period in question. For one resident reviewed for unnecessary medications, the facility did not follow its antibiotic stewardship protocols. The resident, who had diagnoses including metabolic encephalopathy, chronic kidney disease stage 4, and altered mental status, was administered antibiotics for a urinary tract infection (UTI) despite laboratory results suggesting colonization or contamination rather than infection. The resident's care plan included both treatment and prophylactic antibiotics, and medication administration records confirmed that these were given as ordered. However, progress notes and lab results indicated that urine cultures showed multiple organisms with no predominant species, and the resident did not exhibit classic symptoms of UTI. Staff interviews revealed that antibiotics were continued even when McGeer's criteria were not met, and the process for reviewing these criteria was not consistently followed. Further interviews with clinical staff and the medical director highlighted inconsistencies in the application of antibiotic stewardship practices. The infection preventionist noted an increase in antibiotic prescribing for UTIs that did not meet established criteria, and the APRN acknowledged not always using McGeer's criteria, citing altered mental status as a justification. The medical director stated that antibiotics should not be continued without culture sensitivity and suggested alternative treatments. The facility's own policy requires oversight and monitoring of antibiotic use to minimize resistance, but these procedures were not adhered to, resulting in the administration of antibiotics without proper indication.