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F0881
F

Failure to Implement Antibiotic Stewardship and Infection Surveillance

Overland Park, Kansas Survey Completed on 06-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control program. Specifically, the facility did not provide evidence of tracking and trending organism identifications for several months, including December 2024, January 2025, and February 2025, as required by their infection control log. When requested, the facility was unable to produce documentation of trending for these months. Additionally, the antibiotic surveillance binder lacked tracking and trending of eye infections for two residents who were prescribed antibiotic ophthalmic solutions for bacterial conjunctivitis and conjunctivitis/blepharitis. Interviews with facility staff revealed that tracking and trending were reportedly done in real-time, but the administrative nurse could not account for months prior to March 2025, citing changes in infection preventionists. Documentation for March, April, and May was reportedly maintained by the administrator, but earlier months were not available. The facility's infection surveillance policy indicated that infection surveillance is a core activity intended to identify infections and monitor adherence to infection prevention practices, but the lack of documentation and trending for the specified months demonstrated a failure to implement these practices.

See complete original report
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