Failure to Implement Antibiotic Stewardship and Infection Control Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program as required by its own policy and regulatory expectations. Record review showed that there was no documentation of tracking, follow-up, or review with the physician or nurse practitioner after antibiotics were prescribed for three active physician antibiotic orders. Additionally, there was no documented information related to antibiotic use or infection surveillance for a period spanning from August 2024 through June 2025. The facility's policy outlined the need for monitoring antibiotic use, staff education, and tracking of related issues, but these actions were not carried out. Interviews with facility leadership, including the DON, Infection Preventionist, Administrator, and Medical Director, confirmed the absence of an active infection control or antibiotic stewardship program. The DON was unable to provide infection rates or data, relying solely on staff reports. The Infection Preventionist could not produce evidence of any infection prevention activities, including line listings, tracking, or surveillance. The Administrator acknowledged that the program should be in place but was not aware of current infection data, and the Medical Director confirmed the lack of an infection control program, stating that monitoring and tracking were not occurring.