Failure to Implement Antibiotic Stewardship Program and Complete Required Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, specifically by not completing antibiotic review forms for residents who were prescribed antibiotics. The Infection Preventionist (IP Nurse) acknowledged responsibility for completing these forms in the residents' electronic medical records (EMRs) upon admission or when antibiotics were prescribed, using the McGeer Criteria to determine appropriateness. However, for four residents who received antibiotics for various infections, the antibiotic review forms were not completed, and there was no documented determination of whether the antibiotic use met the facility's criteria for appropriate use. The Director of Nursing confirmed that antibiotic surveillance was not completed for these residents, which was contrary to facility policy. The residents involved were prescribed antibiotics for conditions such as Clostridium difficile infection, urinary tract infections, and osteomyelitis. The facility's policy required that antibiotic usage and outcome data be collected and documented using a facility-approved tracking form, but this process was not followed for the residents reviewed.