Inadequate Monitoring and Documentation of Antibiotic Use
Penalty
Summary
The facility failed to adequately monitor and track antibiotic use among residents, as evidenced by record reviews and staff interviews. The antibiotic stewardship program was found to be lacking in consistent and complete documentation. Although the Director of Nursing (DON) stated that antibiotic use was discussed in daily clinical, weekly risk, and monthly QAPI meetings, the stewardship binder and meeting minutes reviewed by the surveyor contained incomplete or missing information. Key details such as resident admission dates, lab results, signs and symptoms, antibiotic start and end dates, and side effects were frequently absent from the records. The DON indicated that some of the documentation was maintained by the pharmacist and that reviews were conducted through the electronic medical record system, but this information was not consistently reflected in the meeting minutes or stewardship binder. Specifically, two residents who were prescribed antibiotics for urinary tract infections were not listed in the facility's risk meeting minutes, and their antibiotic use was not adequately tracked in the available documentation. The DON acknowledged these gaps when questioned by the surveyor. The lack of comprehensive and consistent monitoring and documentation of antibiotic use led to the identified deficiency in the facility's antibiotic stewardship program.