Failure to Follow Antibiotic Stewardship Program and Documentation Protocols
Penalty
Summary
The facility failed to implement and follow its Antibiotic Stewardship Program for all residents reviewed who were receiving antibiotics. Specifically, the McGeers tool, which is intended to determine whether residents meet criteria for antibiotic use, was either not completed, completed after antibiotics were started, or filled out incorrectly for multiple residents. For example, one resident was admitted with sepsis and a urinary tract infection and received Macrobid, but the McGeers tool indicated criteria were not met, yet antibiotics were still administered. Another resident with a follicular disorder received Cephalexin for wounds, but the McGeers tool was completed incorrectly and after antibiotics had already been started. Additionally, several residents admitted from the hospital with ongoing antibiotic orders did not have the McGeers tool or any standardized assessment completed upon admission to determine the appropriateness of continuing antibiotics. In some cases, the facility relied solely on hospital orders without conducting its own assessment, and in others, documentation such as the Antibiotic Time Out form was missing. For one resident with multiple antibiotic orders for wounds and infections, the facility was unable to provide any completed McGeers tools or Antibiotic Time Out forms for the antibiotics administered.