Failure to Implement and Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program in accordance with its own policies and procedures. The policies required the establishment of an antimicrobial stewardship team, use of McGeer's criteria to define infections, and specific documentation and reassessment protocols for antibiotic use. However, record reviews revealed that antibiotics were prescribed and continued for residents whose symptoms did not meet the facility's infection criteria, and there was a lack of clear documentation regarding the rationale for antibiotic use and continuation. For one resident with an upper respiratory infection concern, surveillance indicated that the case did not meet the criteria for infection, yet an antibiotic was prescribed for five days. The nursing progress notes initially lacked documentation of symptoms, and a late entry was made only after the antibiotic usage was questioned. Physician and nurse practitioner notes did not provide further specific signs or symptoms to justify continued antibiotic use, nor did they document the rationale for ongoing therapy despite not meeting McGeer criteria. Another resident was prescribed a seven-day course of antibiotics for a skin concern that also did not meet the infection criteria. Nursing notes mentioned swelling, but there was no further documentation of infection signs or symptoms, and physician and nurse practitioner notes did not address the infection or provide justification for antibiotic use. During an interview, the DON acknowledged that documentation should include all signs and symptoms of infection and the prescriber's rationale for antibiotic use, especially when criteria are not met, but this was not consistently present in the records reviewed.