Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary antibiotics. A resident with multiple diagnoses, including chronic kidney disease, anxiety disorder, hypertension, dementia, and anemia, was prescribed Nitrofurantoin for urinary tract infection (UTI) prophylaxis. The resident’s care plan did not document a history of UTIs or the use of prophylactic antibiotics. Despite this, physician orders continued the daily administration of Nitrofurantoin for several months without a documented rationale or stop date. The electronic medical record lacked evidence of physician review or justification for the ongoing use of the antibiotic. Additionally, the facility was unable to provide documentation of monthly antibiotic use review for the resident, as required by their Antibiotic Stewardship Program Policy. Administrative staff could not locate physician progress notes supporting the continued use of Nitrofurantoin, and the monthly antibiotic log was not provided upon request. These actions and omissions resulted in the resident receiving an antibiotic without documented need or oversight, constituting a failure to ensure the drug regimen was free from unnecessary medications.