Antibiotic Administered Without Confirmed Infection
Penalty
Summary
The facility failed to ensure that an antibiotic was not used without the presence of a diagnosed infection for one of four residents reviewed for antibiotic stewardship. According to the facility's policy, after an antibiotic order is received, the infection control coordinator or designee should complete a surveillance document using the McGeer criteria to confirm evidence of infection, and if the criteria are not met, the physician should be contacted. In this case, a resident was admitted and subsequently had a urinalysis (UA) performed, which showed abnormal results, but no culture and sensitivity (CNS) was ordered or documented. Despite the lack of a confirmed infection or supporting culture results, the resident was prescribed Macrodantin for seven days. Documentation in the resident's screening evaluation form indicated that the antibiotic was ordered as prophylaxis for an abnormal UA, not for a diagnosed urinary tract infection (UTI). The Infection Preventionist confirmed that the antibiotic was ordered based on a dipstick result performed by hospice, which appeared abnormal, but there was no evidence provided to the physician of a urine culture indicating bacterial growth. This sequence of actions did not align with the facility's antibiotic stewardship policy, as there was no documented infection or culture evidence to justify the antibiotic use.