Failure to Discontinue Unnecessary Antibiotic Therapy After Negative C. diff Result
Penalty
Summary
A resident with a medical history including hypertension, right femur fracture, history of falls, peripheral vascular disease, and non-infective gastroenteritis and colitis was admitted to the facility. The resident developed loose stool for one day, prompting a physician order for a stool test for Clostridium difficile (C. diff) and a prophylactic order for oral Vancomycin. The C. diff test result returned negative the following day, but the Vancomycin order for prophylaxis continued, and the resident received the antibiotic multiple times daily for several days after the negative result. Despite the negative C. diff result, physician orders and the Medication Administration Record showed that Vancomycin was administered through at least 6/12, with a continued order for administration until 6/15. The Infection Preventionist confirmed that the antibiotic should have been discontinued after the negative test result. Facility policy requires systematic efforts to optimize antibiotic use, including discontinuation when antibiotics are no longer needed, but this was not followed in this case.