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F0881
E

Failure to Implement Antibiotic Stewardship and Monitoring

Lutz, Florida Survey Completed on 06-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a system to monitor antibiotic use and antibiotic-resistant organisms for a resident admitted with a history of Methicillin-resistant Staphylococcus aureus and an unspecified bacterial infection. Review of the resident's Medication Administration Record (MAR) showed administration of intravenous Vancomycin over several weeks, but there was no documentation specifying the reason for the antibiotic, the type of infection being treated, or a corresponding diagnosis. Physician orders did not include contact precautions, and there was no use of McGreer's Criteria to monitor or classify the infection. Interviews with facility leadership revealed that the antibiotic stewardship program consisted only of color-coded charting of residents on antibiotics, without systematic tracking or use of standardized criteria. The Director of Nursing confirmed that McGreer's Criteria were not in use for monitoring, and the Nursing Home Administrator stated that there was no established infection control or antibiotic monitoring program in place at the time of the resident's admission and treatment. The facility's policy required an antibiotic stewardship program, but it was not effectively implemented or maintained.

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