Failure to Implement and Monitor Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement and monitor its antibiotic stewardship protocol as required. Record reviews and interviews revealed that antibiotic use monitoring was not completed for four consecutive months. Specifically, the Antibiotic Stewardship Book lacked surveillance documentation for August, and the forms for May, June, and July were incomplete and missing required information. The infection mapping for these months was also absent. The DON, who serves as the Infection Preventionist, was unable to locate necessary forms and had not provided education to nurses on how to properly complete the surveillance forms. Additionally, she acknowledged that she had not educated staff on infection control practices. The facility's policy requires comprehensive documentation for antibiotic prescriptions, including dose, route, duration, start and end dates, planned days of therapy, and indication. Audits of antibiotic prescriptions and monitoring of community-acquired infection prevalence data are also mandated, with findings to be presented at monthly Quality Assurance meetings. However, the DON could not provide evidence of such discussions or documentation for several months, nor could she locate point prevalence rates for the same period. The DON stated that she does not allow prophylactic antibiotic orders by physicians, but the lack of surveillance and documentation indicates the protocol was not followed as outlined in facility policy.