Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program with protocols and a system to monitor antibiotic use. Review of facility policies indicated requirements for monitoring, documenting, and reviewing antibiotic use, including the use of an antibiotic surveillance tracking form and oversight by the Infection Preventionist (IP). However, the facility was unable to provide evidence of an active Antibiotic Stewardship Program or documentation of antibiotic use monitoring as required by their own policies and CDC guidance. A resident with a history of septic pulmonary embolism and acute hepatitis was prescribed Levaquin for a positive wound culture over a 14-day period. The medical record did not contain documentation of signs or symptoms of infection or a review of the antibiotic use for this resident. The facility could not provide a line listing of infection signs, symptoms, or culture results for the resident. Interviews with the DON and Administrator confirmed that there was no oversight or documentation of the Antibiotic Stewardship Program at the time of the survey.