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F0881
F

Failure to Implement Antibiotic Stewardship Program

Holton, Kansas Survey Completed on 08-26-2025

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 efforts. A review of the Infection Control Log for the period from August 2024 through July 2025 revealed missing documentation, including organism identifications, duration of antibiotic prescriptions, and the specific infections treated. When requested, the facility was unable to provide evidence of tracking antibiotic use, as the binder for antibiotic surveillance could not be located. Administrative staff confirmed the inability to locate more than one month of surveillance records. The facility's own Antibiotic Stewardship policy, revised in June 2023, stated the purpose was to optimize antibiotic use and reduce unnecessary laboratory tests through a systematic approach, but the required documentation and tracking were not in place.

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