Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to follow its antibiotic stewardship program, resulting in a resident being prescribed an antibiotic for a presumed urinary tract infection (UTI) without confirmation of the infection. The resident's electronic medical record indicated that an antibiotic was started, and although a urine specimen was collected for analysis, it was never picked up by the laboratory. Despite the lack of laboratory confirmation, the resident continued to receive the antibiotic. During an interview, the DON stated that nurses use McGeer's criteria and an SBAR form to determine the need for antibiotics and that residents on antibiotics are monitored as part of the stewardship program. However, the resident's record did not contain a completed SBAR form or documentation of a urinalysis. Facility policies require the implementation of antibiotic use protocols and monitoring as part of the infection prevention and control program, but these protocols were not followed in this instance.