Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with protocols for antibiotic use and a system to monitor antibiotic use. Review of facility records showed that, out of a census of 51 residents and a sample of 15, seven residents received antibiotics during the review period. However, the infection control surveillance log did not document tracking or trending of antibiotic use for residents with recurrent urinary tract infections who received gentamycin bladder irrigations or for those who received amoxicillin for urinary tract infection. The log lacked documentation for these cases, and the administrative nurse confirmed that antibiotic use was not consistently tracked or trended, and that the July log was incomplete. Interviews with administrative nursing staff revealed that antibiotics were prescribed by physicians, but the facility did not conduct formal reviews or audits to determine the appropriateness or effectiveness of antibiotic use. The administrative nurse stated that documentation was typically completed at the end of each month and not tracked daily. Additionally, the facility's infection control policy did not address the identified areas of concern related to antibiotic stewardship and monitoring.