Failure to Implement and Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program as outlined in its policy, which requires monitoring and documentation of antibiotic use among residents. During the survey, there was no evidence of tracking, follow-up, or review with physicians or nurse practitioners after antibiotics were prescribed for any of the seven active antibiotic orders. Additionally, there was no documented information related to antibiotic stewardship for a period spanning from August 2024 through June 2025. The facility's policy also mandates staff orientation, training, and education on the importance of antibiotic stewardship and its impact on residents and the community, but there was no documentation to show these activities were occurring. Interviews with the DON and the Administrator confirmed that antibiotics should be tracked, documented, and reported, but revealed that the facility did not have an active Infection Preventionist in place. The DON acknowledged that while she is informed during morning meetings if someone is on antibiotics, she has not been tracking or monitoring specific data related to antibiotic stewardship and does not maintain line listings. The Administrator also confirmed the absence of an Infection Preventionist and stated that a staff member had been assisting with the program but was no longer available.