Failure to Monitor and Document Antibiotic Use for Resident with C. diff History
Penalty
Summary
The facility failed to develop and implement protocols and a system to monitor antibiotic use for a resident with a history of Clostridium difficile who was currently receiving antibiotics. Interviews with the Infection Prevention (IP) Nurse revealed that although the resident was removed from contact isolation due to the absence of symptoms, there was an expectation for nurses to monitor and document antibiotic assessments and any side effects. However, it was acknowledged that there was no policy in place requiring nurses to document these assessments, and documentation was not being completed as expected. Review of the resident's records showed that the only monitoring documented was related to the use of Doxycycline and Amoxicillin for underarm skin microbiota. The resident's bowel movements were noted to be loose or putty-like over several days, but there was no consistent documentation of daily antibiotic assessments or monitoring for adverse effects as outlined in the care plan. The care plan did include interventions to monitor for side effects of antibiotics every shift, but these were not being followed or documented by staff.